Educational value of the transplant experience in urology residency.

INTRODUCTION To evaluate the educational value of transplant rotation in urology residency. In the United States, exposure to kidney transplantation during urology residency has declined significantly over the past few decades. At our institution, transplantation has been a core component of urology residency since its inception in 1959. MATERIALS AND METHODS: A 15-question anonymous survey was developed. The first 8 questions queried demographics and the last 7 were a set of questions with a Likert Scale response. The survey was electronic- mailed to past and current urology residents who had completed the transplant rotation, dating back to 1972. RESULTS: A total of 61 out of 98 (62%) individuals responded. The majority (59%) were general urologists, and one (2%) had completed a transplant fellowship. In their practices, 17% performed kidney transplants and 28% performed donor nephrectomies. Overall, 100% responded that the skills learned on the transplant rotation were beneficial for urology training, 100% had learned valuable vascular surgical techniques, and 93% felt that urology residents should have clinical transplant experience during their training. There was no statistical difference between the younger and older graduates in Likert scale responses. CONCLUSION: The majority of graduates did not perform transplants in their practice, yet, all of responders agreed that the skills learned on the transplant rotation were beneficial and 93% expressed that urology residents should have clinical transplant experience during residency. Kidney transplantation should be an integral part of urology residency training.

Misaligned Incentives in Benign Prostatic Enlargement Surgery: More Complex and Efficacious Procedures Are Earning Fewer Relative Value Units.

Background: Relative value units (RVUs) are the measure of value used in US Medicare reimbursement. Medicare determines physician work RVUs (wRVUs) from the Relative Value Update Committee (RUC) for a procedure based on operative time, technical skill and effort, mental effort and judgment, and stress. In theory, work RVUs should account for the complexity and operative time involved in a procedure. The aim of this study was to assess whether major procedures for treatment of benign prostatic enlargement (BPE) are fairly compensated based on complexity and operative time in the RVU system and compare them with the intended reimbursement. Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database and the Centers for Medicare and Medicaid Services (CMS) Medicare Physician Fee Schedule were queried from 2015 to 2017. Single, current, procedural terminology codes associated with BPE treatments were included: transurethral resection of the prostate (TURP), photovaporization of the prostate (PVP), holmium laser enucleation of the prostate (HoLEP), retropubic simple prostatectomy (RSP), and suprapubic simple prostatectomy (SSP). The CMS operative times and the NSQIP real data were used in turn to calculate separate values for wRVUs per hour (wRVUs/hr) of operative time. The wRVUs/hr derived from CMS operative times represent RUC-estimated wRVUs/hr and wRVUs/hr derived from NSQIP represent actual wRVUs/hr. Results: A total of 27,664 cases were included from the NSQIP dataset. Median wRVU was 15.3 (interquartile range [IQR] 12.2-15.3), median operative time 50 minutes (IQR 33-74), and median wRVUs/hr 17.0 (IQR 11.6-26.2). RUC-estimated wRVUs/hr were TURP 12.2, PVP 12.2, RSP 9, SSP 9.3, and HoLEP 7.3. The actual wRVUs/hr were TURP 19.1, PVP 15.5, RSP 10.2, HoLEP 9.4, and SSP 7.6. Conclusions: Laser enucleation and simple prostatectomy are highly complex and efficacious procedures for treating BPE, yet the current payment schedule assigns these procedures the least amount of wRVUs/hr. Financial incentives for performing BPE surgeries are clearly misaligned.

Relative value units do not adequately account for operative time in pediatric urology.

BACKGROUND: Relative value units (RVUs) are the measure of value used in United States Medicare and Medicaid reimbursement. The Relative Update Committee (RUC) determines physician work RVU (wRVUs) based on operative time, technical skill and effort, mental effort and judgment, and stress. The primary aim of this study was to assess whether operative time is adequately accounted for in the wRVU system in pediatric urology. METHODS: The American College of Surgeons National Surgical Quality Improvement Program Pediatric Participant User File (ACS-NSQIPP-PUF) was reviewed from 2012 to 2017. Most common single pediatric urology current procedural terminology (CPT) codes were included. The primary variable was wRVU per hour of operative time (wRVU/h). Linear regression analysis was used to assess the relative influence that operative time had on wRVU/h. RESULTS: 25,432 cases were included in the final study population from 45 unique CPT codes. The median operative time was 79 min, and the median RVU/h was 12.2. Procedures with operative time less than 79 min had higher wRVU/h compared with procedures longer than 79 min (14.5 vs 10.5, p < 0.001). Procedures with higher than average incidence of any complications had a lower wRVU/h (9.0 vs. 14.6 p < 0.001). Linear regression analysis revealed that each additional hour of operative time was expected to decrease wRVU/h by 4.2 (-0.70 per 10 min, 95% CI: -0.71 to -0.69, p < 0.001; R2 = 0.39). CONCLUSION: This analysis of contemporary large pediatric population national-level data suggests that the wRVU system significantly favors shorter and less complex procedures in Pediatric Urology. Pediatric urologists performing longer and more complex procedures are not adequately compensated for the increase in complexity. EVIDENCE LEVEL III: Retrospective comparative study.

An institutional assessment of sperm cryospreservation and fertility counselling in pubertal male cancer survivors.

INTRODUCTION: Improved survivorship after treatment of pediatric malignancies has dramatically increased, while pre-treatment fertility preservation in this population has not kept pace. New guidelines emphasize fertility preservation in young adolescents, but the impact of these guidelines is unknown. OBJECTIVES: We sought to evaluate the rate of fertility preservation among at-risk adolescents diagnosed with cancer at our institution, as well as evaluate barriers to fertility preservation. DESIGN: We performed an IRB-approved historical cohort study of adolescent males 13 years and older evaluated in the Pediatric Hematology-Oncology clinic at Doernbecher Children's Hospital from 2010 to 2018. Electronic chart review was used assess discussion of fertility preservation and barrier to successful preservation in boys with a new diagnosis of cancer who received systemic chemotherapy and/or gonadal or pelvic irradiation. RESULTS: 82 boys were included in the study. Forty-two (51%) received counselling about fertility preservation, and of those 29 (70%) successfully banked sperm. Neither counseling for fertility preservation nor success at sperm banking differed by patient age, but both differed by malignancy. Patients with Hodgkin's lymphoma had the highest rate of counselling, while those with leukemia had the lowest. Acute illness as a barrier to preservation was found in 40% of those who did not receive counselling. DISCUSSION: Our study demonstrates a stagnant rate of fertility counseling and preservation despite increased advocacy. The retrospective nature of our study limited our ability to assess the counselling that occurred, and the lack of granular race data limited study of the implicit selection bias that may be involved in such counseling. As more institutions move toward a multi-disciplinary care model, we believe that pediatric urologists or fertility specialists must play a vocal role in the care of these at-risk adolescents. CONCLUSION: Despite increasing advocacy for fertility preservation, our data shows no significant change in previously reported trends. Patients with Hodgkin's lymphoma have a higher rate of counseling and cryopreservation in comparison to those with other malignancies.

RUC Operative Time Estimates are Inaccurate, Resulting in Decreased Work RVU Assignments for Longer Urologic Procedures.

OBJECTIVE: To assess whether inaccurate operative time estimates utilized by the Relative Value Update Committee (RUC) contribute to the undervaluation of longer urologic procedures. METHODS: The National Surgical Quality Improvement Program (NSQIP) and Centers for Medicare and Medicaid Services (CMS) data sets were reviewed from 2015 to 2017. NSQIP operative time is directly measured, contrasting with CMS times which are determined by the RUC via survey-generated estimates. The 50 most frequently coded urology current procedural terminologies were included. Operative time difference was compared between the 2 data sets, and Spearman's correlation coefficient was utilized to assess differences in wRVU/h. RESULTS: A total of 105,931 cases were included. Overall, RUC operative time estimates were longer than NSQIP (124.4 vs 103.5 minutes, P < .001). RUC data overestimated operative time by 42.9% for procedures ≤90 minutes and 16.4% for longer procedures (P < .001). Using NSQIP, procedures ≤90 minutes had higher wRVU/h than longer procedures (12.2 vs 8.7, P < .001), but this was not statistically different using RUC estimates (8.4 vs 7.7, P = .13). Spearman's correlation coefficient confirmed a statistically significant negative relationship between wRVU/h and operative time using NSQIP data (r = -0.57, 95% confidence interval: -7.4 to -0.36), and no statistically significant relationship using RUC data (r = -0.24, 95% confidence interval: -0.49 to 0.04). CONCLUSION: The RUC-intended wRVU/h is more equitable than the NSQIP real-world wRVU/h with regard to operative time. Inaccurate RUC operative time estimates contribute to the undervaluation of longer urologic procedures.

Work relative value units do not account for complexity and operative time in hypospadias surgery.

INTRODUCTION: Relative value units (RVU) are the measure of value used in United States Medicare and Medicaid reimbursement. The Relative Update Committee (RUC) determine physician work RVU (wRVU) based on operative time, technical skill and effort, mental effort and judgement, and stress. In theory, wRVU should account for the complexity and operative time involved in a procedure. OBJECTIVE: The primary aim of this study is to assess if operative time and complexity of hypospadias surgery is adequately accounted for by the current wRVU assignments. STUDY DESIGN: The American College of Surgeons National Surgical Quality Improvement Program Participant User File (ACS-NSQIP PUF) database was utilized from 2012 to 2017. Single stage hypospadias current procedural terminology (CPT) codes (including acceptable secondary CPT codes) were extracted. Using total wRVU and total operative time, the primary variable of wRVU per hour was calculated (wRVU/hr). Multivariable linear regression analysis was used to assess the relative influence that wRVU and operative time had on the wRVU/hr variable. RESULTS: 9810 cases were included in the final study population divided into four categories: simple distal (eg. MAGPI, V-Flap), single stage distal, single stage mid, single stage proximal. On analysis of variance, there was statistically significant different wRVU/hr for the four different types of hypospadias repairs with simple distal having the highest mean wRVU/hr of 19.5 and the lowest being proximal hypospadias repairs at 13.2. Simple distal, distal and midshaft hypospadias had statistically significantly higher wRVU/hr compared to proximal hypospadias (16.2, 95% CI: 15.8-16.5 vs. 13.2, 95% CI 10.9-15.5; p<0.001). Multivariable linear regression revealed that each additional hour of operative time was expected to decrease wRVU/hr by 10.5 (-10.5, 95% CI: -11.0 to -10.1, p < 0.001); total work wRVU had a statistically significant independent association with wRVU/hr (0.6, 95%CI: 0.5-0.7, p <0.001). DISCUSSION: This the first objective assessment of the current wRVU assignments with regards to one stage hypospadias repairs. More complex and longer hypospadias procedures are not adequately compensated by wRVU. Most notably, simple distal procedures are reimbursed at a mean of 19.5 wRVU/hr compared to 13.2 wRVU/hr for one stage proximal repairs. CONCLUSION: This analysis of national-level data suggests that the current wRVU assignments significantly favor shorter and simpler procedures in hypospadias surgery.