National Recommendations against Prostate Specific Antigen Screening versus Statewide Medicaid Expansion Initiatives: A Battle of the Titans.

PURPOSE: Medicaid expansion under the Patient Protection and Affordable Care Act occurred almost concurrently with 2012 U.S. Preventive Services Task Force recommendations against prostate specific antigen screening. Here the relative influence on prostate specific antigen screening rates by 2 concurrent and opposing system-level policy initiatives is investigated: improved access to care and change in clinical practice guidelines. MATERIALS AND METHODS: Behavioral Risk Factor Surveillance System data from years 2012 to 2018 were analyzed for trends in self-reported prostate specific antigen screening and insurance coverage. Subanalyses included state Medicaid expansion status and respondent federal poverty level. Multivariable logistic regression was performed to evaluate factors associated with prostate specific antigen screening. RESULTS: From 2012 to 2018 prostate specific antigen screening predominantly declined with a notable exception of an increase of 7.3% for men at <138% federal poverty level between 2011 and 2013 in early expansion states. Initial increases did not continue, and screening trends mirrored those of nonexpansion states by 2018. Notably, 2014 planned expansions states did not follow this trend with minimal change between 2015 and 2017 compared to declines in early expansion states and nonexpansion states (-0.4% vs -6.7% and -8.6%, respectively). CONCLUSIONS: Medicaid expansion was associated with increased rates of insured men at <138% federal poverty level from 2012 to 2018 in early expansion states. In this group, initial increases in prostate specific antigen screening were not durable and followed the trend of reduced screening seen across the United States. In planned expansions states the global drop in prostate specific antigen screening from 2016 to 2018 was offset in men at <138% federal poverty level by expanding access to care. Nonexpansion states showed a steady decline in prostate specific antigen screening rates. This suggests that policy such as U.S. Preventive Services Task Force recommendations against screening competes with and often outmatches access to care.

Prostate Cancer Screening in Early Medicaid Expansion States.

PURPOSE: The PPACA (Patient Protection and Affordable Care Act) of 2010 included a provision to expand Medicaid by 2014. Six states and jurisdictions elected to expand Medicaid early before 2012. This provided a natural experiment to test the association between expanded insurance coverage and preventive service utilization, including prostate cancer screening. MATERIALS AND METHODS: Using the 2012 and 2014 BRFSS (Behavioral Risk Factor Surveillance System) surveys we identified men 40 to 64 years old who reported prostate specific antigen testing in the preceding 12 months. Sociodemographic and access to care variables were extracted. Income was stratified by the relationship to Medicaid eligibility and the federal poverty level (less than 138%, 138% to 400% and greater than 400%). The weighted prevalence of prostate specific antigen was estimated. Multivariable logistic regression models were used to evaluate factors associated with prostate specific antigen screening. Interaction analysis for Medicaid expansion was performed. RESULTS: Among 158,103 respondents individuals in nonexpansion states had the highest incidence of prostate specific antigen screening. Nationally screening decreased between 2011 and 2013 (OR 0.87, 95% CI 0.83-0.91). In only early expansion states there was a 3% absolute increase in screening among men in the less than 138% federal poverty level, which was associated with expansion status (pinteraction = 0.04). Increased screening in early expansion states was also seen in men who were 55 to 59 years old, nonHispanic African American, Hispanic, previously married, not high school graduates and current smokers. CONCLUSIONS: Between 2011 and 2013 there were national declines in prostate cancer screening. However, there was significant narrowing of the gap in prostate specific antigen screening between higher and low income men in Medicaid early expansion states. This may reflect improved access to preventive services among populations with historic barriers to care.

Systematic Review of the Volume-Outcome Relationship for Radical Prostatectomy.

CONTEXT: Radical prostatectomy (RP) is one of the most complex urological procedures performed. Higher surgical volume has been found previously to be associated with better patient outcomes and reduced costs to the health care system. This has resulted in some regionalization of care toward high-volume facilities and providers; however, the preponderance of RPs is still performed at low-volume institutions. OBJECTIVE: To provide an updated systematic review of the association of hospital and surgeon volume on patient and system outcomes after RP, including robot-assisted RP. EVIDENCE ACQUISITION: A systematic review of literature was undertaken, searching PubMed (1959-2016) for original articles. Selection criteria included RP, hospital and/or surgeon volumes as predictor variables, categorization of hospital and/or surgeon volumes, and measurable end points. EVIDENCE SYNTHESIS: Overall 49 publications fulfilled the inclusion criteria. Most of the studies demonstrated that higher-volume surgeries are associated with better outcomes including reduced mortality, morbidity, postoperative complications, length of stay, readmission, and cost-associated factors. The volume-outcome relationship is maintained in robotic surgery. Eleven studies assessed hospital and surgeon volume simultaneously, and findings reflect that neither is an independent predictor variable affecting outcomes. The studies varied in how volume cutoffs were categorized as well as how the volume-outcome relationship was methodologically evaluated. CONCLUSIONS: Contemporary evidence continues to support the relationship between high-volume surgeries with improved RP outcomes. Recent studies demonstrate that the volume-outcome relationship applies to robot-assisted RP and may be applied for potential cost savings in health care. An increase in the number of international studies suggests reproducibility of the association. Although regionalization of surgical care remains a contentious issue, there is an increasing body of evidence that short-term outcomes are improved at high-volume centers for RP. PATIENT SUMMARY: This systematic review of the latest literature found that higher surgical volume was associated with improved outcomes for radical prostatectomy.

The Use of Prostate Specific Antigen Screening in Purchased versus Direct Care Settings: Data from the TRICARE® Military Database.

PURPOSE: Fee for service reimbursement incentives may affect care. We compared the odds of prostate specific antigen screening among former and active duty United States military service members based on receipt of primary care from integrated military health facilities vs community providers reimbursed via fee for service. MATERIALS AND METHODS: We retrospectively studied the records of all active duty and retired male service members 40 to 64 years old who were covered by the TRICARE® military health benefit in 2010. Beneficiaries may receive primary care at military run facilities via the direct care system or with private physicians via the purchased care system. We compared rates of prostate specific antigen screening between propensity score weighted cohorts of 219,290 men who received primary care in the direct care system and 177,748 who received it in the purchased care system. RESULTS: The screening rate was 35% in the direct care system vs 26% in the purchased care system. After propensity score weighting the former men were significantly more likely to undergo prostate specific antigen screening than men who received primary care in the purchased care system (adjusted OR 1.76, 95% CI 1.729-1.781). Age older than 52 years, rank and black race were associated with increased odds of prostate specific antigen screening in each cohort. CONCLUSIONS: These results suggest that salaried primary care providers employed at integrated military facilities are more likely to order prostate specific antigen screening compared to those reimbursed in a fee for service fashion by military insurance. Growing understanding of how fee for service incentives impact prostate specific antigen screening by primary care providers may enable advocates and policy makers to leverage reimbursement systems as a tool to change prostate cancer screening.

Emergency Department Utilization in Patients With Neurogenic Bladder: Contemporary Burden and National Trends in Prevalence, Inpatient Admission, and Associated Charges, 2006-2011.

OBJECTIVE: To quantify the national burden of neurogenic bladder disease, a chronic debilitating condition associated with frequent hospital visits, in the contemporary emergency care setting. METHODS: Relying on the Nationwide Emergency Department Sample, 2006-2011, we abstracted patients presenting to the emergency department (ED) with neurogenic bladder utilizing International Classification of Diseases, Ninth Revision (ICD-9) codes. National trends in ED presentation, subsequent inpatient admission vs discharge, and associated charges were examined using the estimated annual percent change methodology. RESULTS: Over the study period, a total of 875,066 patients with neurogenic bladder were seen in the ED, of which 538,532 (61.5%) were admitted. Total and median ED charges increased at an annual rate of 36.66% (P <.001) and 13.24% (P <.001), respectively, with total ED charges amounting to 87.48 million USD in the year 2011. Annual ED utilization also increased, although at a slower rate, 1.89% (P = .017). Inpatient admissions decreased at an annual rate of 3.67% (P <.001), whereas the use of long-term care facilities increased at 11.82% (P = .005). CONCLUSION: Total ED charges are increasing at a dramatic rate, driven by the increasing utilization of the ED as an entry point to health care as well as the increasing per-visit charges. Encouragingly, the rates of inpatient admission are decreasing, likely secondary to improved triaging in the ED and increased utilization of long-term care facilities. It remains to be seen, however, whether the increased spending in the ED for better triaging and investment in long-term care facilities will translate into an overall economic benefit by reducing inpatient charges or not.

Accountable care organizations and the use of cancer screening.

Cancer preventive services, when used appropriately, result in improved health, better quality of life and decreased costs. For these reasons, cancer preventive services represent important priorities within the Affordable Care Act (ACA). Among the many provisions to improve access to preventive services the ACA introduced Accountable Care Organizations (ACOs) as trajectory to deliver coordinated, high-quality care. In order to evaluate this benchmark, we analyzed (in 2016/Boston) screening prevalence of breast cancer, a recommended screening test according to the United States Preventive Services Task Force (USPSTF), and prostate cancer, for which screening is no longer recommended by the USPSTF, among traditional Medicare beneficiaries and those enrolled in ACOs. We used propensity-score weighting to adjust for baseline confounders. We found that the prevalence of breast cancer screening (35.0% vs. 25.2%, p<0.001) and prostate cancer screening (54.6% vs. 41.7%, p<0.001) is higher among ACO enrollees. Our results suggest increased utilization of cancer preventive care within ACOs, regardless of whether the test is recommended or not. Better efforts may be needed within the ACO infrastructure to encourage recommended preventive care, but also penalize unnecessary use of low value services.

Healthcare policy and urologic practice.

PURPOSE OF REVIEW: Healthcare policy is currently a topic of national debate, with numerous implications for the practice of urology. RECENT FINDINGS: Healthcare policy has broad reaching effects, both predicted and unforeseen. The effects of healthcare policy are manifested through clinical practice guidelines, payment reform and the overall structure of the healthcare system. This review describes each of these topics and their impact on clinical practice, with a specific focus on urology and urologic practice. SUMMARY: Guidelines are useful for guiding and determining what is considered appropriate clinical practice, but there are drawbacks including poor implementation and overabundance. Payment reform is constantly evolving, with multiple efforts being implemented to move away from a fee-for-service model of reimbursement. The structure of healthcare delivery is moving toward more outpatient procedures, with varying amount of physician ownership of facilities and equipment, which is itself a controversial topic.

Surgeon and Hospital Level Variation in the Costs of Robot-Assisted Radical Prostatectomy.

PURPOSE: We assessed surgeon and hospital level variation in robot-assisted radical prostatectomy costs and predictors of high and low cost surgery. MATERIALS AND METHODS: The study population consisted of a weighted sample of 291,015 men who underwent robot-assisted radical prostatectomy for prostate cancer by 667 surgeons at 197 U.S. hospitals from 2003 to 2013. We evaluated 90-day direct hospital costs (2014 USD) in the Premier Hospital Database. High costs per robot-assisted radical prostatectomy were those above the 90th percentile and low costs were those below the 10th percentile. RESULTS: Mean hospital cost per robot-assisted radical prostatectomy was $11,878 (95% CI $11,804-$11,952). Mean cost was $2,837 (95% CI $2,805-$2,869) in the low cost group vs $25,906 (95% CI $24,702-$25,490) in the high cost group. Nearly a third of the variation in robot-assisted radical prostatectomy cost was attributable to hospital characteristics and more than a fifth was attributable to surgeon characteristics (R-squared 30.43% and 21.25%, respectively). High volume surgeons and hospitals (90th percentile or greater) had decreased odds of high cost surgery (surgeons: OR 0.24, 95% CI 0.11-0.54; hospitals: OR 0.105, 95% CI 0.02-0.46). The performance of robot-assisted radical prostatectomy at a high volume hospital was associated with increased odds of low cost robot-assisted radical prostatectomy (OR 839, 95% CI 122-greater than 999). CONCLUSIONS: This study provides insight into the role of surgeons and hospitals in robot-assisted radical prostatectomy costs. Given the substantial variability, identifying and remedying the root cause of outlier costs may yield substantial benefits.

Robot-assisted Versus Open Radical Prostatectomy: A Contemporary Analysis of an All-payer Discharge Database.

BACKGROUND: More than a decade since its inception, the benefits and cost efficiency of robot-assisted radical prostatectomy (RARP) continue to elicit controversy. OBJECTIVE: To compare outcomes and costs between RARP and open RP (ORP). DESIGN, SETTING, AND PARTICIPANTS: A cohort study of 629 593 men who underwent RP for localized prostate cancer at 449 hospitals in the USA from 2003 to 2013, using the Premier Hospital Database. INTERVENTION: RARP was ascertained through a review of the hospital charge description master for robotic supplies. OUTCOME MEASURES AND STATISTICAL ANALYSIS: Outcomes were 90-d postoperative complications (Clavien), blood product transfusions, operating room time (ORT), length of stay (LOS), and direct hospital costs. Propensity-weighted regression analyses accounting for clustering by hospitals and survey weighting ensured nationally representative estimates. RESULTS AND LIMITATIONS: RARP utilization rapidly increased from 1.8% in 2003 to 85% in 2013 (p<0.001). RARP patients (n=311 135) were less likely to experience any complications (odds ratio [OR] 0.68, p<0.001) or prolonged LOS (OR 0.28, p<0.001), or to receive blood products (OR 0.33, p=0.002) compared to ORP patients (n=318 458). The adjusted mean ORT was 131min longer for RARP (p=0.002). The 90-d direct hospital costs were higher for RARP (+$4528, p<0.001), primarily attributed to operating room and supplies costs. Costs were no longer signficantly different between ORP and RARP among the highest-volume surgeons (≥104 cases/yr; +$1990, p=0.40) and highest-volume hospitals (≥318 cases/yr; +$1225, p=0.39). Limitations include the lack of oncologic characteristics and the retrospective nature of the study. CONCLUSIONS: Our contemporary analysis reveals that RARP confers a perioperative morbidity advantage at higher cost. In the absence of large randomized trials because of the widespread adoption of RARP, this retrospective study represents the best available evidence for the morbidity and cost profile of RARP versus ORP. PATIENT SUMMARY: In this large study of men with prostate cancer who underwent either open or robotic radical prostatectomy, we found that robotic surgery has a better morbidity profile but costs more.

The impact of Medicare eligibility on cancer screening behaviors.

INTRODUCTION: Lack of health insurance limits access to preventive services, including cancer screening. We examined the effects of Medicare eligibility on the appropriate use of cancer screening services in the United States. METHODS: We performed a cross-sectional analysis of the 2012 Behavioral Risk Factor and Surveillance System (analyzed in 2014). Univariable and logistic regression analyses were performed for participants aged 60-64 and 66-70 to examine the effects of Medicare eligibility on prevalence of self-reported screening for colorectal, breast, and prostate cancers. Sub-analyses were performed among low-income (<$25,000 annual/household) individuals. RESULTS: Medicare-eligible individuals were significantly more likely to undergo all examined preventive services (colorectal cancer OR: 1.90; 95% CI 1.79-2.04; prostate cancer OR: 1.29; 95% CI 1.17-1.43; breast cancer OR: 1.23; 95% CI 1.10-1.37) and the effect was most pronounced among low-income individuals (colorectal cancer OR: 2.04; 95% CI 1.8-2.32; prostate cancer OR: 1.39; 95% CI 1.12-1.72; breast cancer OR: 1.42, 95% CI 1.20-1.67). Access to a healthcare provider was the strongest independent predictor of undergoing appropriate screening, ranging from OR 2.73 (95% CI 2.20-3.39) for colorectal cancer screening in the low-income population to OR 4.79 (95% CI 3.95-5.81) for breast cancer screening in the overall cohort. The difference in screening prevalence was most pronounced when comparing Medicare-eligible participants to uninsured Medicare-ineligible participants (+33.2%). CONCLUSIONS: Medicare eligibility impacts the prevalence of cancer screening, likely as a result of increased access to primary care. Low-income individuals benefit most from Medicare eligibility. Expanded public insurance coverage to these individuals may improve access to preventive services.

Racial Differences in the Surgical Care of Medicare Beneficiaries With Localized Prostate Cancer.

IMPORTANCE: There is extensive evidence suggesting that black men with localized prostate cancer (PCa) have worse cancer-specific mortality compared with their non-Hispanic white counterparts. OBJECTIVE: To evaluate racial disparities in the use, quality of care, and outcomes of radical prostatectomy (RP) in elderly men (≥ 65 years) with nonmetastatic PCa. DESIGN, SETTING, AND PARTICIPANTS: This retrospective analysis of outcomes stratified according to race (black vs non-Hispanic white) included 2020 elderly black patients (7.6%) and 24,462 elderly non-Hispanic white patients (92.4%) with localized PCa who underwent RP within the first year of PCa diagnosis in the Surveillance, Epidemiology, and End Results (SEER)-Medicare database between 1992 and 2009. The study was performed in 2014. MAIN OUTCOMES AND MEASURES: Process of care (ie, time to treatment, lymph node dissection), as well as outcome measures (ie, complications, emergency department visits, readmissions, PCa-specific and all-cause mortality, costs) were evaluated using Cox proportional hazards regression. Multivariable conditional logistic regression and quantile regression were used to study the association of racial disparities with process of care and outcome measures. RESULTS: The proportion of black patients with localized prostate cancer who underwent RP within 90 days was 59.4% vs 69.5% of non-Hispanic white patients (P < 001). In quantile regression of the top 50% of patients, blacks had a 7-day treatment delay compared with non-Hispanic whites. (P < 001). Black patients were less likely to undergo lymph node dissection (odds ratio [OR], 0.76 [95% CI, 0.66-0.80]; P < .001) but had higher odds of postoperative visits to the emergency department (within 30 days: OR, 1.48 [95% CI, 1.18-1.86]); after 30 days or more (OR, 1.45 [95% CI, 1.19-1.76]) and readmissions (within 30 days: OR, 1.28 [95% CI, 1.02-1.61]); ≥ 30 days (OR, 1.27 [95% CI, 1.07-1.51]) compared with non-Hispanic whites. The surgical treatment of black patients was associated with a higher incremental annual cost (the top 50% of blacks spent $1185.50 (95% CI , $804.85-1 $1566.10; P < .001) more than the top 50% of non-Hispanic whites). There was no difference in PCa-specific mortality (P = .16) or all-cause mortality (P = .64) between black and non-Hispanic white men. CONCLUSIONS AND RELEVANCE: Blacks treated with RP for localized PCa are more likely to experience adverse events and incur higher costs compared with non-Hispanic white men; however, this does not translate into a difference in PCa-specific or all-cause mortality.

Racial/Ethnic Disparities in Perioperative Outcomes of Major Procedures: Results From the National Surgical Quality Improvement Program.

OBJECTIVE: To determine the association between race/ethnicity and perioperative outcomes in individuals undergoing major oncologic and nononcologic surgical procedures in the United States. BACKGROUND: Prior work has shown that there are significant racial/ethnic disparities in perioperative outcomes after several types of major cardiac, general, vascular, orthopedic, and cancer surgical procedures. However, recent evidence suggests attenuation of these racial/ethnic differences, particularly at academic institutions. METHODS: We utilized the American College of Surgeons National Surgical Quality Improvement Program database to identify 142,344 patients undergoing one of the 16 major cancer and noncancer surgical procedures between 2005 and 2011. RESULTS: Eighty-five percent of the cohort was white, with black and Hispanic individuals comprising 8% and 4%, respectively. In multivariable analyses, black patients had greater odds of experiencing prolonged length of stay after 10 of the 16 procedures studied (all P < 0.05), though there was no disparity in odds of 30-day mortality after any surgery. Hispanics were more likely to experience prolonged length of stay after 5 surgical procedures (all P < 0.04), and were at greater odds of dying within 30 days after colectomy, heart valve repair/replacement, or abdominal aortic aneurysm repair (all P < 0.03). Fewer disparities were observed for Hispanics, than for black patients, and also for cancer, than for noncancer surgical procedures. CONCLUSIONS: Important racial/ethnic disparities in perioperative outcomes were observed among patients undergoing major cancer and noncancer surgical procedures at American College of Surgeons National Surgical Quality Improvement Program institutions. There were fewer disparities among individuals undergoing cancer surgery, though black patients, in particular, were more likely to experience prolonged length of stay.

Racial Disparities in End-of-Life Care Among Patients With Prostate Cancer: A Population-Based Study.

OBJECTIVE: To examine racial disparities in end-of-life (EOL) care among black and white patients dying of prostate cancer (PCa). METHODS: Relying on the SEER-Medicare database, 3789 patients who died of metastatic PCa between 1999 and 2009 were identified. Information was assessed regarding diagnostic care, therapeutic interventions, hospitalizations, intensive care unit (ICU) admissions, and emergency department visits in the last 12 months, 3 months, and 1 month of life. Logistic regression tested the relationship between race and the receipt of diagnostic care, therapeutic interventions, and high-intensity EOL care. RESULTS: Overall, 729 patients (19.24%) were black. In the 12-months preceding death, laboratory tests (odds ratio [OR], 0.51; 95% CI, 0.36-0.72), prostate-specific antigen test (OR, 0.54; 95% CI, 0.43-0.67), cystourethroscopy (OR, 0.71; 95% CI, 0.56-0.90), imaging procedure (OR, 0.58; 95% CI, 0.41-0.81), hormonal therapy (OR, 0.53; 95% CI, 0.44-0.65), chemotherapy (OR, 0.59; 95% CI, 0.48-0.72), radiotherapy (OR, 0.74; 95% CI, 0.61-0.90), and office visit (OR, 0.38; 95% CI, 0.28-0.50) were less frequent in black versus white patients. Conversely, high-intensity EOL care, such as ICU admission (OR, 1.27; 95% CI, 1.04-1.58), inpatient admission (OR, 1.49; 95% CI, 1.09-2.05), and cardiopulmonary resuscitation (OR, 1.72; 95% CI, 1.40-2.11), was more frequent in black versus white patients. Similar trends for EOL care were observed at 3-month and 1-month end points. CONCLUSIONS: Although diagnostic and therapeutic interventions are less frequent in black patients with end-stage PCa, the rate of high-intensity and aggressive EOL care is higher in these individuals. These disparities may indicate that race plays an important role in the quality of care for men with end-stage PCa.

Incidence, admission rates, and economic burden of pediatric emergency department visits for urinary tract infection: data from the nationwide emergency department sample, 2006 to 2011.

BACKGROUND: The Emergency Department (ED) is being increasingly utilized as a pathway for management of acute conditions such as the urinary tract infections (UTIs). OBJECTIVE: We sought to assess the contemporary trends in pediatric UTI associated ED visits, subsequent hospitalization, and corresponding financial expenditure, using a large nationally representative pediatric cohort. Further, we describe the predictors of admission following a UTI associated ED visit. METHODS: The Nationwide Emergency Department Sample (NEDS; 2006-2011) was queried to assess temporal-trends in pediatric (age ≤17 years) ED visits for a primary diagnosis of UTI (ICD9 CM code 590.X, 595.0, and 599.0), subsequent hospital admission, and total charges. These trends were examined using the estimated annual percent change (EAPC) method. Multivariable regression models fitted with generalized estimating equations (GEE) identified the predictors of hospital admission. RESULTS: Of the 1,904,379 children presenting to the ED for management of UTI, 86 042 (4.7%) underwent hospital admission. Female ED visits accounted for almost 90% of visits and increased significantly (EAPC 3.28%; p = 0.003) from 709 visits per 100 000 in 2006 to 844 visits per 100 000 in 2011. Male UTI incidence remained unchanged over the study-period (p = 0.292). The overall UTI associated ED visits also increased significantly during the study-period (EAPC 3.14%; p = 0.006) because of the increase in female UTI associated ED visits. Overall hospital admissions declined significantly over the study-period (EAPC -5.59%; p = 0.021). Total associated charges increased significantly at an annual rate of 18.26%, increasing from 254 million USD in 2006 to 464 million USD in 2011 (p < 0.001; Figure). This increase in expenditure was likely driven by increased utilization of diagnostic CT scanning in these patients (EAPC 22.86%; p < 0.001). Ultrasonography (p = 0.805), X-ray (p = 0.196), and urine analysis/culture use (p = 0.121) did not change over the study-period. In multivariable analysis, the independent predictors of admission included younger age (p < 0.001), male gender (OR = 2.05, p < 0.001), higher comorbidity status (OR = 14.81, p < 0.001), pyelonephritis (OR = 4.45, p < 0.001) and concurrent hydronephrosis (OR = 49.42, p < 0.001), stone disease (OR = 6.44, p < 0.001), or sepsis (OR = 18.83, p < 0.001). DISCUSSION: We show that the incidence of ED visits for pediatric UTI is on the rise. This rise in incidence could be due to several factors, including increasing prevalence of metabolic conditions such as obesity, diabetes and metabolic syndrome in children predisposing them to infections, or could be secondary to increasing sexual activity amongst adolescents and changing patterns of contraceptive use (increased use of OCP in place of condoms), or more simply might just be a reflection of changing practice patterns. Second, we demonstrate that total charges for management of UTI in the ED setting are increasing rapidly; the increase is primarily driven by increasing utilization of diagnostic imaging in the ED setting, as has been demonstrated in other ED based studies as well. CONCLUSIONS: In children presenting to the ED with a primary diagnosis of UTI, total ED charges are increasing at an alarming rate not commensurate with the increase in overall ED visits. While the preponderance of children presenting to the ED for UTI are treated and discharged, 4.7% of patients were admitted to the hospital for further management. The strongest predictors of inpatient admission were pyelonephritis, younger age, male gender, higher comorbidity status, and concurrent hydronephrosis, stone disease, or sepsis. Managing these at-risk patients more aggressively in the outpatient setting may prevent unnecessary ED visits and subsequent hospitalizations, and reduce associated healthcare costs.

Burden of hospital admissions and utilization of hospice care in metastatic prostate cancer patients.

OBJECTIVE: To examine the rates of hospitalization in patients with metastatic prostate cancer (mCaP), as well as the effect of hospice utilization on the cost patterns of mCaP. Over the past decade, dramatic changes in the management of advanced prostate cancer have proceeded alongside changes in end-of-life care. But, the impact of these contemporary advances in management of mCaP and its implications on US health care expenditure remains unknown. METHODS: Patients hospitalized with mCaP from 1998 to 2010 were extracted from the Nationwide Inpatient Sample (n = 100,220). Temporal trends in incidence and charges were assessed by linear regression. Complex samples logistic regression models were used to identify the predictors of in-hospital mortality, elevated hospital charges beyond the 75th percentile and hospice utilization. RESULTS: Between 1998 and 2010, admissions for mCaP decreased at a rate of -5.95% per year (P <.001), whereas per-incident charges increased at the rate of 6.1% (P <.001) annually; the national economic burden of care was stable. Over the study period, hospice use increased 488.0% per year (P <.001) but was significantly lower among black (odds ratio [OR], 0.73; P = .01) and Hispanic (OR, 0.65; P = .03) patients. In multivariable analyses, hospice utilization was associated with decreased odds of elevated hospital charges beyond the 75th percentile (OR, 0.84; P = .02). CONCLUSION: Despite a decline in hospitalizations for mCaP, the economic burden of care has remained stable. Increasing use of hospice services has moderated the effect of rising per-incident hospital charges, highlighting the importance of promoting access to hospice in the right clinical setting. These findings have important policy implications, particularly as advances in treatment are expected to further increase expenditures related to the inpatient management of mCaP.

Racial disparities in operative outcomes after major cancer surgery in the United States.

BACKGROUND: Numerous studies have recorded racial disparities in access to care for major cancers. We investigate contemporary national disparities in the quality of perioperative surgical oncological care using a nationally representative sample of American patients and hypothesize that disparities in the quality of surgical oncological care also exists. METHODS: A retrospective, serial, and cross-sectional analysis of a nationally representative cohort of 3,024,927 patients, undergoing major surgical oncological procedures (colectomy, cystectomy, esophagectomy, gastrectomy, hysterectomy, pneumonectomy, pancreatectomy, and prostatectomy), between 1999 and 2009. RESULTS: After controlling for multiple factors (including socioeconomic status), Black patients undergoing major surgical oncological procedures were more likely to experience postoperative complications (OR: 1.24; p < 0.001), in-hospital mortality (OR: 1.24; p < 0.001), homologous blood transfusions (OR: 1.52; p < 0.001), and prolonged hospital stay (OR: 1.53; p < 0.001). Specifically, Black patients have higher rates of vascular (OR: 1.24; p < 0.001), wound (OR: 1.10; p = 0.004), gastrointestinal (OR: 1.38; p < 0.001), and infectious complications (OR: 1.29; p < 0.001). Disparities in operative outcomes were particularly remarkable for Black patients undergoing colectomy, prostatectomy, and hysterectomy. Importantly, substantial attenuation of racial disparities was noted for radical cystectomy, lung resection, and pancreatectomy relative to earlier reports. Finally, Hispanic patients experienced no disparities relative to White patients in terms of in-hospital mortality or overall postoperative complications for any of the eight procedures studied. CONCLUSIONS: Considerable racial disparities in operative outcomes exist in the United States for Black patients undergoing major surgical oncological procedures. These findings should direct future health policy efforts in the allocation of resources for the amelioration of persistent disparities in specific procedures.

The burden of skeletal-related events in patients with prostate cancer and bone metastasis.

BACKGROUND: To assess contemporary characteristics, hospital admissions, charges, and mortality in patients with prostate cancer (CaP) who have bone metastases and skeletal-related events in an observational study. METHODS: Relying on the Nationwide Inpatient Sample (NIS), patients with CaP with bone metastases between 1998 and 2010 were abstracted. Patients who experienced skeletal-related events were identified, and hospital charges were calculated. Generalized linear regression analyses focused on in-hospital mortality. RESULTS: Between 1998 and 2010, a weighted estimate of 443,929 CaP visits with bone metastases was recorded. Of these, 15.9% experienced at least 1 SRE. The rate of SRE decreased from 18% to 15.4% (1998-2010, estimated annual percent change [EAPC] =-1.44%, P = 0.005) and the SRE-associated mortality decreased from 8.5% to 4.7% (1998-2010, EAPC =-3.68%, P = 0.004). Nevertheless, the inflation-adjusted charges associated with hospital visits of patients with CaP with bone metastases rose by 92% to $1,512,449,106 (EAPC = +8.82%, P<0.001), and SRE charges rose by 94% to $369,256,799 (EAPC =+7.62%, P<0.001). Predictors of in-hospital mortality in patients with SRE included age (odds ratio [OR] = 1.02), comorbidities (≥3 vs. 0-1, OR = 1.72), SRE of the upper limb (OR = 1.75), SRE of the lower limb (OR = 1.35), spinal cord compression (OR = 1.48), radiation (OR = 0.68), surgery (OR = 0.32), and year of hospitalization (2010 vs. 1998, OR = 0.54; all P< 0.03). CONCLUSIONS: From 1998 to 2010, the incidence of SRE and SRE-associated mortality in patients with CaP and bone metastases decreased. However, charges for SRE-associated hospitalizations have increased alarmingly. Future health care policies should strive to provide cost-effective prevention and management of SREs in this population.

Getting back to equal: The influence of insurance status on racial disparities in the treatment of African American men with high-risk prostate cancer.

OBJECTIVES: Treating high-risk prostate cancer (CaP) with definitive therapy improves survival. We evaluated whether having health insurance reduces racial disparities in the use of definitive therapy for high-risk CaP. MATERIALS AND METHODS: The Surveillance, Epidemiology, and End Results Program was used to identify 70,006 men with localized high-risk CaP (prostate-specific antigen level > 20 ng/ml or Gleason score 8-10 or stage > cT3a) diagnosed from 2007 to 2010. We used multivariable logistic regression to analyze the 64,277 patients with complete data to determine the factors associated with receipt of definitive therapy. RESULTS: Compared with white men, African American (AA) men were significantly less likely to receive definitive treatment (adjusted odds ratio [AOR] = 0.60; 95% CI: 0.56-0.64; P < 0.001) after adjusting for sociodemographics and known CaP prognostic factors. There was a significant interaction between race and insurance status (P interaction = 0.01) such that insurance coverage was associated with a reduction in racial disparity between AA and white patients regarding receipt of definitive therapy. Specifically, the AOR for definitive treatment for AA vs. white was 0.38 (95% CI: 0.27-0.54, P < 0.001) among uninsured men, whereas the AOR was 0.62 (95% CI: 0.57-0.66, P < 0.001) among insured men. CONCLUSIONS: AA men with high-risk CaP were significantly less likely to receive potentially life-saving definitive treatment when compared with white men. Having health insurance was associated with a reduction in this racial treatment disparity, suggesting that expansion of health insurance coverage may help reduce racial disparities in the management of aggressive cancers.