Association of household net worth with healthcare costs after radical cystectomy using real-world data.

BACKGROUND: Financial toxicity of bladder cancer care may influence how patients utilize healthcare resources, from emergency department (ED) encounters to office visits. We aim to examine whether greater household net worth (HHNW) confers differential access to healthcare resources after radical cystectomy (RC). METHODS: This population-based cohort study examined the association between HHNW and healthcare utilization costs in the 90 days post-RC in commercially insured patients with bladder cancer. Costs accrued from the index hospitalization to 90 days after including health plan costs (HPC) and out-of-pocket costs (OPC). Multivariable logistic regression models were generated by encounter (acute inpatient, ED, outpatient, and office visit). RESULTS: A total of 141,903 patients were identified with HHNW categories near evenly distributed. Acute inpatient encounters incurred the greatest HPC and OPC. Office visits conferred the lowest HPC while ED visits had the lowest OPC. Black patients harbored increased odds of an acute inpatient encounter (OR 1.22, 95% CI 1.16-1.29) and ED encounter (OR 1.20, 95% CI 1.14-1.27) while Asian (OR 0.76, 95% CI 0.69-0.85) and Hispanic (OR 0.74, 95% CI 0.69-0.78, p < 0.001) patients had lower odds of an outpatient encounter, compared to White counterpart. Increasing HHNW was associated with decreasing odds of acute inpatient or ED encounters and greater odds of office visits. CONCLUSIONS: Lower HHNW conferred greater risk of costly inpatient encounters while greater HHNW had greater odds of less costly office visits, illustrating how financial flexibility fosters differences in healthcare utilization and lower costs. HHNW may serve as a proxy for financial flexibility and risk of financial hardship than income alone.

Applicant perceptions of virtual interviews for society of urologic oncology fellowships during the COVID-19 pandemic.

The COVID-19 public health emergency forced the conversion of in-person SUO fellowship interviews into virtual interviews. We sought to understand applicant perspectives and preferences related to virtual interviews and whether programs should consider virtual interviews in the future. We distributed a survey to 2020 SUO Fellowship interview participants at 4 SUO urologic oncology fellowship programs. Response items were on a Likert scale scored 1-5 with higher scores indicating greater agreement with the survey item construct. Survey responses were collated and thematic mapping used to describe open text responses. Descriptive statistics were used for analysis of survey and open text results. Fifty-eight SUO fellowship applicants completed the survey. Virtual interviews successfully promoted interaction with SUO fellowship program faculty (mean 4.6, SD 0.6), outlined program research opportunities (mean 4.5, SD 0.7), and proffered opportunities to ask questions about the fellowship (mean 4.7, SD 0.5). Applicants exhibited weakly positive orientation to the adequacy of the virtual format (mean 3.5, SD 1.1). 63% of applicants would prefer a virtual format in the future. Qualitative feedback noted the benefits of virtual interviews were lower cost and reduced time away from residency. SUO fellowship applicants exhibited mixed preferences for virtual and in-person interviews. Although virtual fellowship interviews have benefits such as cost savings and time efficiency, notable weaknesses included challenges observing the culture of the programs. Following the pandemic, SUO fellowship programs may consider virtual interviews but should consider incorporating opportunities for informal interactions between faculty, fellows, and fellow applicants.

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.

Evaluating the impact of surgical supply cost variation during partial nephrectomy on patient outcomes.

BACKGROUND: Reducing surgical supply costs can help to lower hospital expenditures. We aimed to evaluate whether variation in supply costs between urologic surgeons performing both robotic or open partial nephrectomies is associated with differential patient outcomes. METHODS: In this retrospective cohort study, we reviewed 399 consecutive robotic (n=220) and open (n=179) partial nephrectomies performed at an academic center. Surgical supply costs were determined at the institution-negotiated rate. Through retrospective review, we identified factors related to case complexity, patient comorbidity, and perioperative outcomes. Two radiologists assigned nephrometry scores to grade tumor complexity. We created univariate and multivariable models for predictors of supply costs, length of stay, and change in serum creatinine. RESULTS: Median supply cost was $3,201 [interquartile range (IQR): $2,201-3,808] for robotic partial nephrectomy and $968 (IQR: $819-1,772) for open partial nephrectomy. Mean nephrometry score was 7.0 (SD =1.7) for robotic procedures and 8.2 (SD =1.6) for open procedures. In multivariable models, the surgeon was the primary significant predictor of variation in surgical supply costs for both procedure types. In multivariable mixed-effects analysis with surgeon as a random effect, supply cost was not a significant predictor of change in serum creatinine for robotic or open procedures. Supply cost was not a statistically significant predictor of length of stay for the open procedure. Supply cost was a significant predictor of longer length of stay for the robotic procedure, however it was not a clinically meaningful change in length of stay (0.02 days per $100 in supply costs). CONCLUSIONS: Higher supply spending did not predict significantly improved patient outcomes. Variability in surgeon supply preference is the likely source of variability in supply cost. These data suggest that efforts to promote cost-effective utilization and standardization of supplies in partial nephrectomy could help reduce costs without harming patients.

Operating Room Supply Cost Awareness: A Cross-Sectional Analysis.

INTRODUCTION: We assessed surgeon knowledge of commonly used instruments and disposable items and described attitudes toward incorporating cost data into daily practice. METHODS: An electronic, e-mail based survey was distributed to faculty and trainees in the University of California San Francisco (UCSF) Department of Urology. The 26-question survey assessed opinions regarding general operating room supply cost information and specific costs of 10 supplies used for laparoscopic nephrectomy. A response was considered accurate when it fell within 50% of the actual cost. RESULTS: The response rate was 71% among faculty (13) and 90% among trainees (17). Overall 55% of faculty and 82% of trainees considered their knowledge of costs "fair" or "poor." The overall accuracy of cost estimation for 10 commonly used supply items was 27% (SD ± 45%), with no significant difference between trainees and faculty (p=0.70). Accuracy was not associated with self-reported cost knowledge (p=0.25) or number of laparoscopic nephrectomies performed (p=0.47). Of the faculty 33% and of the trainees 41% reported that having more knowledge of costs would motivate them to decrease their operating room supply costs, and 42% of faculty raised the idea of an incentive program. Overall 75% of study participants believe that there is "too little" or "not enough" emphasis placed on cost awareness. CONCLUSIONS: Trainees and faculty generally have poor knowledge of operating room supply costs. In our academic setting we noted an interest among faculty and residents to make cost data more accessible. These data would provide an opportunity for surgeons to act as cost arbiters in the operating room.

Development and validation of surgical training tool: cystectomy assessment and surgical evaluation (CASE) for robot-assisted radical cystectomy for men.

BACKGROUND: We aimed to develop a structured scoring tool: cystectomy assessment and surgical evaluation (CASE) that objectively measures and quantifies performance during robot-assisted radical cystectomy (RARC) for men. METHODS: A multinational 10-surgeon expert panel collaborated towards development and validation of CASE. The critical steps of RARC in men were deconstructed into nine key domains, each assessed by five anchors. Content validation was done utilizing the Delphi methodology. Each anchor was assessed in terms of context, score concordance, and clarity. The content validity index (CVI) was calculated for each aspect. A CVI ≥ 0.75 represented consensus, and this statement was removed from the next round. This process was repeated until consensus was achieved for all statements. CASE was used to assess de-identified videos of RARC to determine reliability and construct validity. Linearly weighted percent agreement was used to assess inter-rater reliability (IRR). A logit model for odds ratio (OR) was used to assess construct validation. RESULTS: The expert panel reached consensus on CASE after four rounds. The final eight domains of the CASE included: pelvic lymph node dissection, development of the peri-ureteral space, lateral pelvic space, anterior rectal space, control of the vascular pedicle, anterior vesical space, control of the dorsal venous complex, and apical dissection. IRR > 0.6 was achieved for all eight domains. Experts outperformed trainees across all domains. CONCLUSION: We developed and validated a reliable structured, procedure-specific tool for objective evaluation of surgical performance during RARC. CASE may help differentiate novice from expert performances.

Variation in Laparoscopic Nephrectomy Surgical Costs: Opportunities for High Value Care Delivery.

INTRODUCTION: Rising health care costs are leading to efforts to minimize costs while maintaining high quality care. Practice variation in the operating room that is not dictated by patient necessity or clinical guidelines presents an opportunity for cost containment. We identified variation in surgical supply costs among urological surgeons performing laparoscopic nephrectomy and evaluated whether this variation was associated with patient outcomes. METHODS: A total of 211 consecutive laparoscopic nephrectomies performed at an academic center between September 1, 2012 and December 31, 2015 were identified and surgical supply costs for each case were determined from the institutional negotiated rate. Patient and surgical factors relevant to case complexity, comorbidity and perioperative outcomes were obtained. Univariate and multivariable analysis of predictors of surgical supply costs and patient outcome as determined by length of stay was conducted. RESULTS: Median supply cost was $2,537, with individual medians ranging from $1,642 to $4,524, representing a significant variation among surgeons (p <0.01). On multivariable analysis, accounting for patient factors and case complexity, most surgeons remained significant predictors of surgical supply costs. Case supply cost was not a significant predictor of patient outcomes as measured by length of stay on univariate or multivariable analysis controlling for surgeon, patient factors and case complexity. CONCLUSIONS: Significant variation in surgeons' surgical supply costs for laparoscopic nephrectomy exists and is driven by surgeons, and this does not correlate with length of stay. Targeting variation in surgical supply costs in this setting represents an opportunity for cost savings without adversely impacting patient outcomes.

The Cancer of the Bladder Risk Assessment (COBRA) score: Estimating mortality after radical cystectomy.

BACKGROUND: Risk stratification of patients with urothelial carcinoma of the bladder (UCB) after cystectomy has important clinical and research implications. The authors assessed the relative effect of tumor stage and lymph node status on cancer-specific survival (CSS) after cystectomy and developed a simplified risk-assessment tool. METHODS: In total, 14,828 patients who underwent cystectomy with lymph node dissection for UCB were identified from the Surveillance, Epidemiology, and End Results database (1988-2011). The relative importance of tumor stage and lymph node status with regard to CSS was assessed using stratified Kaplan-Meier and Cox proportional-hazards analyses. The patients were split randomly into development and validation cohorts. Additional validation using overall survival was performed on 19,362 patients from the National Cancer Data Base. The Cancer of Bladder Risk Assessment (COBRA) tool was created using a Cox model incorporating age, tumor stage, and lymph node density. Performance was validated using observed versus expected survival plots and the Harrell concordance index. RESULTS: Patients with muscle invasive (T2), lymph node-positive disease had a survival curve similar to that in patients with extravesical (T3 and T4), lymph node-negative disease (2-year CSS, 67% and 70%, respectively). Each point increase in the COBRA score (range, 0-7) was associated with a 1.61-fold increase (95% confidence interval, 1.56-fold to 1.65-fold increase) in the risk of bladder cancer death in the development cohort. The model accurately stratified patients across risk levels in the development cohort and the 2 validation cohorts (C-index, 0.712, 0.705, and 0.68, respectively). CONCLUSIONS: The COBRA score offers a straightforward, validated risk-stratification tool that incorporates the relative contribution of tumor stage and lymph node involvement to patient prognosis after cystectomy for UCB. Cancer 2017;123:4574-4582. © 2017 American Cancer Society.

Variation and Predictors of Surgical Case Costs among Urologists.

INTRODUCTION: Shifts in the health care delivery system have emphasized providing cost-efficient care. The operating room comprises a significant proportion of hospital costs. Analysis of practice variation in operating room supply use can provide insight into opportunities for cost reduction and improved efficiency without compromising outcomes. METHODS: A retrospective review was conducted of urological procedures performed at the University of California San Francisco Medical Center from September 2012 through December 2015. Supply costs for individual cases were itemized and aggregated using the institution negotiated rate. Operative time was monetized. Supply cost was analyzed with multivariate mixed effects models evaluating surgeon experience and surgeon volume. RESULTS: The majority of common urological procedures demonstrate significant variation among surgeons in supply, time and overall cost. Surgeon annual procedure specific volume was a significant predictor of lower cost in multivariate analysis of supply cost (p = 0.016) and correlated with a lower likelihood of the case supply cost being in the top quintile (p <0.001). Surgeon experience was not a significant predictor of absolute supply cost or being in the top quintile of supply cost. CONCLUSIONS: Significant variation exists among supply costs of high volume procedures. Higher surgeon procedure specific volume predicts lower operating room supply costs. Targeting procedures with variation for cost optimization via standardization could have a substantial impact on operating room costs and efficiency. The experience of high volume surgeons may be useful to guide optimal supply use given their comparatively lower costs.

Validity of the Cancer of the Prostate Risk Assessment Score Derived From Targeted Biopsy: Modeling Evidence From Ultrasound Lesion-Directed Biopsy.

OBJECTIVE: Our aim was to evaluate the impact of direct, ultrasound lesion-targeted prostate biopsy, alone or in combination with systematic sampling, on prostate cancer risk prediction. MATERIALS AND METHODS: We reviewed biopsy findings for men with known or clinical suspicion of prostate cancer undergoing direct, ultrasound-targeted biopsy of radiographic lesions with concomitant systematic extended peripheral zone biopsy. We examined the resulting tumor volume estimates, Gleason grade, and Cancer of the Prostate Risk Assessment score generated from each strategy. Resulting multivariate clinical models of adverse surgical pathology-defined as high grade (Gleason pattern, ≥ 4+3) or non-organ-confined disease (≥ pT3a) were compared by the area under the Receiver Operating Characteristic curve. RESULTS: A total of 352 patients received ultrasound-targeted biopsy. At diagnosis, the mean age was 63 years, median prostate-specific antigen, 5.7 ng/mL (interquartile range, 4.3-8.2), and median 15 cores (interquartile range, 12-18). The addition of targeted cores to systematic biopsy resulted in reclassification of 52 patients (14.7%) based on Gleason score, 45 (12.8%) by percentage of cores involved > 33%, and 51 (14.5%) by single core positivity > 50%; Cancer of the Prostate Risk Assessment risk category increased in 44 (12.5%). In multivariable logistic regression models of 196 men treated with prostatectomy, the area under the Receiver Operating Characteristic curve for the prediction of adverse pathology generated from targeted (0.754), systematic (0.753), and combined approaches (0.763) were not significantly different (P = .831). CONCLUSIONS: The validity of clinical risk prediction assessed with a multi-variable instrument was maintained in the setting of lesion-targeted biopsy.

Economic analysis of infant vs postpubertal orchiopexy to prevent testicular cancer.

OBJECTIVES: To use decision analysis to determine the economic benefits of early vs late orchiopexy, specifically with respect to testicular cancer development and management. Studies have suggested that prepubertal orchiopexy might confer additional protection from the development of testicular cancer compared with postpubertal orchiopexy. Infant surgery is often performed by pediatric subspecialists and hence might be more costly. Although rare, testicular cancer can require significant medical expenditures. METHODS: We examined the resource index (RI) (physician charges and hospital costs) from the medical establishment's perspective. Economic modeling was performed to determine whether early or late orchiopexy minimized the RI. The stage- and histologic-specific costs of subsequent testicular cancer were incorporated into our models. The variables were tested over realistic ranges in the sensitivity analysis to determine the threshold values. RESULTS: In the base case analysis, the RI for infant and postpubertal orchiopexy was $7500 and $10,928 per patient, respectively. The sensitivity analysis demonstrated that the costs for operating room time, physicians' fees, operative times, and baseline cancer risk were important parameters. However, only the surgeons' fees demonstrated threshold values. The RI for treating cancer and the cancer risk reduction after early orchiopexy did not significantly affect our models. CONCLUSIONS: Our models of orchiopexy for prevention of testicular cancer showed that infant orchiopexy is less costly than later surgery, provided that the surgeons' fees are not excessive. It appears that early surgery might significantly reduce the treatment costs of testicular cancer for cryptorchid boys and supports the current standard of care in the United States.

Outcomes and cost analysis of pyeloplasty for antenatally diagnosed ureteropelvic junction obstruction using Markov models.

OBJECTIVES: The optimal timing of pyeloplasty for children diagnosed with ureteropelvic junction obstruction (UPJO) after workup for antenatal hydronephrosis is disputed. We sought to examine the potential costs and clinical outcomes of treatment protocols featuring different indications for pediatric pyeloplasty using Markov models. METHODS: Cost and outcomes analysis using Markov modeling was performed for three treatment algorithms: medical management, immediate pyeloplasty (during the first year of life), and pyeloplasty after no improvement on imaging. The costs were determined from the perspective of the medical institution. The variables tracked during Markov model simulation included age at resolution of UPJO, the proportion of patients with worsened hydronephrosis, the number of pyeloplasties, the number of pyelonephritis episodes, and costs. Sensitivity analyses were performed to determine which elements affected the model and to determine threshold values. RESULTS: Immediate pyeloplasty and pyeloplasty after no improvement on imaging resulted in rapid resolution of UPJO (mean age at resolution younger than 2 years) with lower rates of worsened hydronephrosis and pyelonephritis compared with observation alone. For the surgical protocols, the costs per resolved case of UPJO were greater than those for medical management alone at the probability values tested in the Markov models. The sensitivity analysis of all variables over realistic ranges demonstrated that the costs of surgery, annual antibiotics and imaging, and the rate of pyelonephritis were critical in determining the costs. CONCLUSIONS: Pediatric urologists should include practice-specific features such as the costs of surgery, annual antibiotics and imaging, and pyelonephritis rates when considering efficacious, yet less costly, treatment protocols for UPJO.

Medical malpractice in American urology: 22-year national review of the impact of caps and implications for contemporary practice.

PURPOSE: Of the economic pressures on physicians practicing in the United States medical malpractice and associated costs are a major component. State tort reform in the form of caps on noneconomic awards has been pursued to control insurance premiums and improve patient access to care. We comprehensively examined jury verdicts involving urologists and determined the nature of these cases and their relationship to changes in tort reform. MATERIALS AND METHODS: We searched the LexisNexis database for all malpractice cases involving urologists using the search terms urologist and malpractice. The query included all cases between 1984 and 2005, which were categorized by state, year, amount and the nature of the injury. RESULTS: We identified 322 jury verdict cases, of which 175 (54%) were in favor of the defendant. In states with caps the median verdict settlement within or outside the periods of caps was $350,000 and $150,000, respectively. States without caps had a median verdict or settlement of $491,500. However, the number of suits and the size of the verdict/settlement in states with and without caps during this period did not appear to be related to tort reform. Common clinical situations, such as prostate cancer and transurethral prostate resection, accounted for most suits. CONCLUSIONS: Although the concept and goals of malpractice caps seem desirable, there is little evidence that decreased physician premiums and improved access to care have been achieved via tort reform. Thus, while state and national legislative efforts to limit the economic burden on urologists continue, the specialty of urology must look to other approaches to improve the situation.

Decision analysis and Markov modeling in urology.

PURPOSE: The process of decision making in medicine has become increasingly complex. This has developed as the result of increasing amounts of data, often without direct information or answers regarding a specific clinical problem. The use of mathematical models has grown and they are commonly used in all areas. We describe and discuss the application of decision analysis and Markov modeling in urology. MATERIALS AND METHODS: We define decision analysis and Markov models, providing a background and primer to educate the urologist. In addition, we performed a complete MEDLINE database search for all decision analyses in all disciplines of urology, serving as a reference summarizing the current status of the literature. RESULTS: The review provides urologists with the ability to critically evaluate studies involving decision analysis and Markov models. We identified 107 publications using decision analysis or Markov modeling in urology. A total of 36 studies used Markov models, whereas the remainder used standard decision analytical models. All areas of urology, including oncology, pediatrics, andrology, endourology, reconstruction, transplantation and erectile dysfunction, were represented. CONCLUSIONS: Decision analysis and Markov modeling are widely used approaches in the urological literature. Understanding the fundamentals of these tools is critical to the practicing urologist.

Markov modeling of vasectomy reversal and ART for infertility: how do obstructive interval and female partner age influence cost effectiveness?

OBJECTIVE: To apply Markov models to assess the cost effectiveness of the relative impact of obstructive interval and female partner age on fertility using either assisted reproductive technology (ART) or vasectomy reversal, and elucidate the impact of these variables on fertility. DESIGN: Markov models based on review of published literature and available ART outcome data. SETTING: University-based clinical practice. PATIENT(S): Simulation runs of 50,000 patients for each analysis. INTERVENTION(S): Varying vasectomy obstructive interval and maternal age. MAIN OUTCOME MEASURE(S): Cost effectiveness, willingness to pay (WTP), and net health benefit. RESULT(S): Base case analysis showed ART yields a higher pregnancy rate and higher cost than vasectomy reversal. Sensitivity analysis showed female age has a greater effect on cost effectiveness than obstructive interval. At a WTP < $65,000, vasectomy reversal is more cost effective than ART. With increasing WTP, ART is more cost effective over wider windows of female age. CONCLUSION(S): Markov modeling of fertility after vasectomy suggests female age has more impact than vasectomy obstructive interval on cost effectiveness.

Cost-utility analysis of treatment algorithms for moderate grade vesicoureteral reflux using Markov models.

PURPOSE: The optimal treatment algorithm for vesicoureteral reflux remains controversial. Previous decision analyses have attempted to determine the best approach solely from the cost or cure perspective but have not combined the goals of minimizing treatment and disease burden. We incorporated these considerations into a contemporary, comprehensive analysis of treatment for vesicoureteral reflux. MATERIALS AND METHODS: We examined costs from the perspective of the medical institution, and utility from the perspective of parents of children with grades II and III vesicoureteral reflux. Cost-utility analysis using Markov modeling was performed to ascertain which of 5 treatment algorithms best minimized morbidity and cost. A higher utility value was based on minimizing treatment and disease burden. Measures of treatment and disease burden included duration of suppressive antibiotics, number of invasive studies, pyelonephritis episodes, endoscopic treatments and open operations. All variables were varied spanning realistic ranges during sensitivity analyses to determine threshold values. RESULTS: The protocol of no antibiotics or followup imaging yielded the best cost-utility for vesicoureteral reflux grades II and III. Sensitivity analysis of variables spanning realistic ranges demonstrated that utility penalties for invasive imaging and outpatient pyelonephritis were particularly important in determining the highest utility protocols, with threshold values ranging from -0.5 to -0.8. CONCLUSIONS: In our models of treatment for vesicoureteral reflux a noninterventional approach constitutes the highest utility and least costly treatment for moderate grade reflux. Given the relative dearth of randomized trials, these analyses provide guidelines for current management of vesicoureteral reflux.

Surgery or assisted reproduction? A decision analysis of treatment costs in male infertility.

PURPOSE: Assisted reproductive technology (ART), including in vitro fertilization and intracytoplasmic sperm injection, is routinely used to treat male factor infertility. Because of the success of ART, the optimal method to achieve pregnancy with male infertility is controversial. Two examples in which ART competes with traditional male infertility treatments are varicocelectomy and vasectomy reversal. We used formal decision analysis to estimate and compare the cost-effectiveness of surgical therapy and ART for varicocele and vasectomy reversal. MATERIALS AND METHODS: Decision analysis models were created for infertile men seeking paternity with varicocele and with post-vasectomy obstruction. Outcome probabilities applied to the model were derived from institutional and published sources. Costs of interventions were calculated from institutional data. Sensitivity analyses determined which elements were most important and, thus, were used to calculate threshold values. RESULTS: Vasectomy reversal is as cost-effective as ART if bilateral vasovasostomy can be performed. However, if unilateral or bilateral vasoepididymostomy is required, sperm retrieval/intracytoplasmic sperm injection may be more cost-effective due to lower patency rates. Vasectomy reversal is more cost-effective across all pregnancy rates provided that patency rates are greater than 79%. Surgical repair of varicocele is more cost-effective when the postoperative pregnancy rate is greater than 14% in men with a preoperative total motile sperm count of less than 10 million sperm and greater than 45% in men with greater than 10 million total motile sperm. CONCLUSIONS: A decision analysis based comparison of ART and classic surgical therapy suggests that varicocelectomy and vasectomy reversal are the most economical treatments in many cases of infertility due to these lesions. Tailoring the decision models to individual centers permits more accurate comparisons using specific costs as well as the surgical outcomes and results of ART.

Sociodemographic characteristics and health related quality of life in men attending prostate cancer support groups.

PURPOSE: Prostate cancer can be associated with anxiety, depression and fears of recurrence and side effects of treatment. Support groups may help meet the needs of patients with cancer by providing treatment information and emotional support. We describe men in prostate cancer support groups and compare them to a national registry. METHODS AND METHODS: Men attending prostate cancer support groups in the San Francisco Bay area completed a questionnaire including sociodemographic and clinical characteristics, health related quality of life items, satisfaction with treatment, relief of prostate cancer symptoms and bother from perceived side effects of treatment. Patients in support groups were compared to men enrolled in a national prostate cancer registry (Cancer of the Prostate Strategic Urological Research Endeavor). RESULTS: Men attending support groups had higher annual income and education levels, lower median serum prostate specific antigen and higher cancer grades than men in Cancer of the Prostate Strategic Urological Research Endeavor. Clinical stage was comparable for the 2 groups. Men in support groups were satisfied with treatment and alleviation from symptoms. Adjusting for ethnicity, marital status, age and type of treatment, sexual function scores were higher in men who attended support groups (p = 0.001). There was no statistically significant difference in bowel and urinary function between groups, although urinary function approached statistical significance at p = 0.05. Sexual and bowel bother scores indicated less bother for men in support groups (p < or = 0.025). CONCLUSIONS: Men enrolled in support groups have unique sociodemographic characteristics. Their health related quality of life appears to be better than that of other men with prostate cancer. Whether this is related to support group participation is not known. Additional studies are required to determine whether routine support group participation improves outcomes in men with prostate cancer.