National Utilization, Reimbursement, and Urban Versus Rural Trends of Extracorporeal Shockwave Lithotripsy and Ureteroscopic Laser Lithotripsy.

OBJECTIVE: To describe temporal utilization and reimbursement trends of extracorporeal shockwave lithotripsy (ESWL) and ureteroscopy (URS) with laser lithotripsy. METHODS: The Medicare Provider Utilization and Payment Database was queried for all ESWL and URS performed between 2013 and 2020 using Current Procedural Terminology codes: ESWL - 50590; URS - 52352, 52353, 52356. Cases that lacked rural or urban identification codes were excluded. A total of 347,174 ESWL and 401,899 URS cases were identified. Linear regression was performed with statistical significance set to 95% confidence intervals. RESULTS: There was a significant upward trend for URS utilization over the study period (R2 = 0.91, P <.001), but there was not a significant trend for ESWL utilization. In 2013, ESWL was used more frequently than URS, but by 2016, URS was used more frequently than ESWL. From 2013 to 2019, URS utilization increased by 241% and 168% by urban and rural urologists, respectively. URS was also associated with a slight increase in physician reimbursement over time (R2 = 0.87, P <.001), whereas there was no association between ESWL and physician reimbursement. For URS, rural and urban urologists were reimbursed an average of $312.07 (standard deviation [SD] $14.03) and $404.86 (SD $21.96), respectively. For ESWL, rural and urban urologists were reimbursed an average of $456.22 (SD $5.74) and $562.66 (SD $16.68), respectively. CONCLUSION: According to the Medicare database, URS has surpassed ESWL in utilization, especially by urban urologists. Physician reimbursement for ESWL remained higher than URS reimbursement, though URS reimbursement increased slightly in recent years.

Use of a Risk Stratification Tool to Guide Evaluation of Patients With Asymptomatic Microscopic Hematuria.

OBJECTIVE: To determine if use of the hematuria risk index can reduce testing and cost, while maintaining equivalent lesion detection in patients with asymptomatic microscopic hematuria. MATERIALS AND METHODS: Retrospective cohort study of 1049 patients at single institution. Hematuria risk index score was calculated based on clinical factors including age, sex, smoking history, and degree of hematuria for each patient along with evaluation studies performed and total number of tumors discovered. Cost benefit analysis was performed based on published Medicare averages. RESULTS: Tumor detection rate in overall, low-risk, and moderate-risk groups were 1.2%, 0%, and 2.96% at a total cost of $408,376. When low-risk group is not screened cost decreases to $166,252 with no lesions missed. The cost to discover one lesion/cancer in the overall group was $34,031.3, the cost to find one high-grade clinically significant lesion/cancer was $136,125.3 for the overall group. When the low-risk group was removed, the cost to find a high-grade clinically significant lesion/cancer decreased to $55,417.3 without missing any significant lesions. Ultrasound may be utilized instead of computed tomography with minimal loss of lesion detection in select moderate risk patients. CONCLUSION: None of the low-risk hematuria risk patients were diagnosed with any lesions, as such these patients may not need an evaluation. Furthermore, by utilizing a risk-stratified approach to the assessment of asymptomatic microscopic hematuria health care costs can be significantly decreased with limited negative consequences in terms of lesion detection.

Contemporary Trends in Percutaneous Nephrolithomy Across New York State: A Review of the Statewide Planning and Research Cooperative System.

Introduction and Objectives: Percutaneous nephrolithotomy (PCNL) is a complex multistep surgery that has shown a steady increase in use for the past decade in the United States. We sought to evaluate the trends and factors associated with PCNL usage across New York State (NYS). Our goal was to characterize patient demographics and socioeconomic factors across high-, medium-, and low-volume institutions. Materials and Methods: We searched the NYS, Statewide Planning and Research Cooperative System (SPARCS) database from 2006 to 2014 using ICD-9 Procedure Codes 55.04 (percutaneous nephrostomy with fragmentation) for all hospital discharges. Patient demographics including age, gender, race, insurance status, and length of hospital stay were obtained. We characterized each hospital as a low-, medium-, or high-volume center by year. Patient and hospital demographics were compared and reported using chi-square analysis and Student's t-test for categorical and continuous variables, respectively, with statistical significance as a p-value of <0.05. Results: We identified a total of 4576 procedures performed from 2006 to 2014 at a total of 77 hospitals in NYS (Table 1). Total PCNL volume performed across all NYS hospitals increased in the past decade, with the greatest number of procedures performed in 2012 to 2013. Low-volume institutions were more likely to provide care to minority populations (21.4% vs 17.3%, p < 0.001) and those with Medicaid (25.5% vs 21.5%, p < 0.001). High-volume institutions provided care to patients with private insurance (42.1% vs 34.0%, p < 0.001) and had a shorter length of stay (3.3 days vs 4.1 days, p < 0.001). Conclusion: Our data provide insight into the patient demographics of those treated at high-, medium-, and low-volume hospitals for PCNL across NYS. Significant differences in race, insurance status, and length of stay were noted between low- and high-volume institutions, indicating that racial and socioeconomic factors play a role in access to care at high-volume centers.

Does Any Racial Disparity Exist in Oncologic Outcomes After Primary Cryotherapy for Prostate Cancer? A Matched-pair Comparative Analysis of the Cryo On-Line Data Registry.

BACKGROUND: African-American (AA) men have the greatest incidence of and disease-specific mortality from prostate cancer of any racial group. Although encouraging oncologic and functional outcomes have been reported with prostate cancer cryotherapy, little is known about how ethnicity can potentially affect the oncologic outcomes of primary cryotherapy. We report the oncologic outcomes of primary cryotherapy in AA patients through a matched-pair analysis. PATIENTS AND METHODS: A 1:2 (AA to non-AA) cohort of patients was designed using the Cryo-On-Line Data Registry. The 2 arms were matched for patient age, prostate-specific antigen level, Gleason score, and prostate volume. The oncologic outcome was defined in terms of the biochemical recurrence (BCR) rates after primary cryoablation using Phoenix criteria. The results of "for-cause" post-treatment biopsies and the BCR-free survival rates were also analyzed between the 2 groups. RESULTS: The 1:2 cohort of AA and non-AA men in the present study included 109 and 218 men, respectively. Their median age (69 vs. 71 years; P = .71), median prostate-specific antigen level (6.5 vs. 6.8 ng/mL; P = .95), median prostate volume (32 vs. 30 cm3; P = .31), Gleason score distribution (P = .97), and prostate cancer risk group (P = .12) were similar statistically. The median postoperative follow-up period was also comparable between the 2 groups (AA, 32 months vs. non-AA, 27 months; P = .52). The BCR rates were similar between the AA and non-AA men (14% vs. 17%; P = .52). Likewise, the rate of positive "for-cause" prostate biopsy findings was similar between the 2 groups (AA vs. non-AA, 25% vs. 36%; P = .44). Furthermore, the 5-year biochemical relapse-free survival rates were comparable for the AA and non-AA patients (74% vs. 71%; P = .37). CONCLUSION: When matched for tumor characteristics, cryotherapy as a treatment modality for primary, clinically localized prostate cancer offers men of African-American descent similar oncologic outcomes to those of non-AA men.

Cost comparison of open and robotic partial nephrectomy using a short postoperative pathway.

OBJECTIVE: To compare immediate perioperative direct costs of open partial nephrectomy (OPN) and robotic partial nephrectomy (RPN), managed under a common care pathway. METHODS: Retrospective review of detailed institutional cost data for patients treated with OPN and RPN during 2011 was conducted. Cost and clinical data of OPN and RPN were compared for all patients and for patients stratified by length of stay (LOS), American Society of Anesthesiologists (ASA), and RENAL nephrometry scores. RESULTS: The study cohort included 190 OPN and 63 RPN cases. OPN was associated with higher ASA scores (P <.001), shorter operative times (P = .014), and higher estimated blood loss (P <.001). Median (interquartile range) LOS was 2 days (2-3 days) for OPN compared with 1 day (1-2 days) for RPN (P <.001). Median perioperative cost of OPN was lower than that of RPN with a difference of $3091 (P <.001). Although hospitalization costs were higher in OPN, surgical costs were higher in RPN ($854 and $3695 difference in median costs, respectively; P <.001 for both). The total cost of OPN for patients with an above-average LOS remained lower than that of RPN ($2680 difference in median costs; P = .001). RPN costs remained significantly higher when stratifying patients by their ASA and RENAL nephrometry scores. CONCLUSION: Despite the shorter hospital LOS associated with RPN, the immediate perioperative cost of OPN was lower than that of RPN for patients managed under a common care pathway, mainly due to high robotic purchase and maintenance costs. In light of the current health care debate, such financial disincentives may compromise the sustainability of advances in medical technology.