The Role of Frailty on Surgical Outcomes Following Pelvic Organ Prolapse Surgery in Medicare Beneficiaries: A National Study.

OBJECTIVE: To evaluate the association of frailty with surgical outcomes following pelvic organ prolapse (POP) surgery in Medicare beneficiaries. METHODS: This is a retrospective cohort study of female Medicare beneficiaries ≥65 years of age undergoing POP surgery between 2014 and 2016. Primary outcomes were hospital length-of-stay (LOS) ≥3 days, 30-day post-operative complications (excluding urinary tract infections (UTI)), and 30-day UTI. Frailty was quantified using the validated Claims-Based Frailty Index (CFI) and categorized into not frail (CFI<0.15), pre-frail (0.15≤CFI<0.25), mildly frail (0.25≤CFI<0.35), and moderately to severely frail (0.35≤CFI≤1). RESULTS: Among the 107,890 women included (mean age, 73.3±6 years), 91.3% were White as and 4.3% were classified as mildly or moderately to severely frail. Rates of hospital LOS≥3 days and 30-day UTI increased over 7-fold and rates of 30-day complications increased over 3-fold as CFI increased from not frail to moderately to severely frail (all P values <.001). Compared to women who were not frail, women who were moderately to severely frail demonstrated an increased relative risk of hospital LOS≥3 days (aRR 3.1 [95% CI 2.5-3.8,P <.001]), 30-day complications (aRR 2.8 [95% CI 2.2-3.6, P <.001]), and 30-day UTI (aRR 2.5 [95% CI 2.2-3.0, P <.001]). CONCLUSION: Among Medicare beneficiaries undergoing POP surgery in the United States, frailty is strongly associated with increased risk of prolonged hospital stay and 30-day complications. Frailty should be considered in the preoperative assessment for POP surgeries to improve patient outcomes.

Functional and cognitive outcomes after suprapubic catheter placement in nursing home residents: A national cohort study.

BACKGROUND: Long-term functional and cognitive outcomes in nursing home residents after procedures are poorly understood. Our objective was to evaluate these outcomes after suprapubic tube (SPT) placement. METHODS: We performed a retrospective, cohort study in the nursing home setting. Participants were long-term nursing home residents who underwent SPT placement from 2014 to 2016 in the United States. SPT placements were identified in Medicare Inpatient, Outpatient, and Carrier files using International Classification of Diseases and Current Procedural Terminology codes. Residents were identified through the Minimum Data Set (MDS) 3.0 for Nursing Home Residents. MDS Activities of Daily Living (MDS-ADL) and Brief Interview for Mental Status (BIMS) scores were used to assess function and cognition, respectively. Outcomes of interest were worsening MDS-ADL and BIMS scores at 1 year postoperatively, 30-day postoperative complications, and 1-year mortality. Functional and cognitive trajectories were modeled to 1 year postoperatively using mixed-effect spline models. RESULTS: From 2014 to 2016, 9647 residents with a mean age of 80.9 (SD 8.1) years underwent SPT placement. At 1 year postoperatively, 37.6% of residents died, while of survivors, 33.7% had worsening MDS-ADL and 36.2% worsened BIMS. Residents had steeper postoperative rates of functional decline compared to relatively stable preoperative trends that never recovered to baseline status. However, robustly characterizing an association between SPT placement and functional decline would require a propensity score matched cohort without SPT placement. Decline in cognitive status was not clearly associated with SPT placement, suggesting either the natural course of a vulnerable population or limitations of BIMS scores. CONCLUSIONS: Outcomes important to older adults, such as functional ability and cognitive status, do not show improvement after SPT placement. These findings emphasize that this "minor" procedure should be considered with caution in this population and primarily for palliation.

Frailty Is Associated with an Increased Risk of Complications and Need for Repeat Procedures after Sling Surgery in Older Adults.

PURPOSE: Sling surgery is the gold standard treatment for stress urinary incontinence in women. While data support the use of sling surgery in younger and middle-aged women, outcomes in older, frail women are largely unknown. MATERIALS AND METHODS: Data were examined for all Medicare beneficiaries ≥65 years old who underwent sling surgery with or without concomitant prolapse repair from 2014 to 2016. Beneficiaries were stratified using the Claims-Based Frailty Index (CFI) into 4 categories: not frail (CFI <0.15), prefrail (0.15 ≤CFI <0.25), mildly frail (0.25 ≤CFI <0.35) and moderately to severely frail (CFI ≥0.35). Outcomes included rates and relative risk of 30-day complications, 1-year mortality and repeat procedures for persistent incontinence or obstructed voiding at 1 year. RESULTS: A total of 54,112 women underwent sling surgery during the study period, 5.2% of whom were mildly to moderately to severely frail. Compared to the not frail group, moderately to severely frail beneficiaries demonstrated an increased adjusted relative risk (aRR) of 30-day complications (56.5%; aRR 2.5, 95% CI: 2.2-2.9) and 1-year mortality (10.5%; aRR 6.7, 95% CI: 4.0-11.2). Additionally, there were higher rates of repeat procedures in mildly to severely frail beneficiaries (6.6%; aRR 1.4, 95% CI: 1.2-1.6) compared to beneficiaries who were not frail. CONCLUSIONS: As frailty increased, there was an increased relative risk of 30-day complications, 1-year mortality and need for repeat procedures for persistent incontinence or obstructed voiding at 1 year. While there were fewer sling surgeries in performed frail women, the observed increase in complication rates was significant. Frailty should be strongly considered before pursuing sling surgery in older women.

Population Trends in Frailty in Older Adults with Benign Urological Conditions in Northern California.

INTRODUCTION: We sought to understand regional variation of frailty across health service areas (HSAs) in Northern and Central California among older adults with benign urological conditions. METHODS: This retrospective study utilizes the University of California, San Francisco Geriatric Urology Database, which includes adults ≥65 years old with benign urological conditions who underwent a Timed Up and Go Test (TUGT) between December 2015 and June 2020. The TUGT is a validated proxy for frailty, whereby a TUGT ≤10 seconds represents robust individuals and a TUGT >10 seconds represents prefrail and frail individuals. Subjects were assigned to the HSA wherein they live, and HSAs were stratified by mean TUGT scores. Analyses were conducted at the HSA level. Characteristics associated with prefrail/frail HSAs were identified using multivariable logistic regression. Least square means were used to determine variation in adjusted mean TUGT scores. RESULTS: A total of 2,596 subjects were stratified into 69 HSAs in Northern and Central California. Twenty-one HSAs were categorized as robust and 48 HSAs were categorized as prefrail/frail. Prefrail/frail HSAs were significantly associated with older age (adjusted odds ratio [aOR] 4.03, CI 3.29-4.94, p <0.001), female sex (aOR 1.10, CI 1.07-1.11, p <0.001), non-White race (aOR 1.12, CI 1.10-1.14, p <0.001), underweight body mass index (BMI; aOR 1.14, CI 1.07-1.22, p <0.001) and obese BMI (aOR 1.06, CI 1.04-1.08, p <0.001). There was a 1.7-fold difference in mean TUGT values across HSAs. CONCLUSIONS: Older age, non-White race, and underweight and obese BMIs are associated with prefrail/frail HSAs. Further investigation into health disparities as they pertain to geography and frailty is needed to expand upon these findings.

Assessment of Frailty and Association With Progression of Benign Prostatic Hyperplasia Symptoms and Serious Adverse Events Among Men Using Drug Therapy.

Importance: Benign prostatic hyperplasia (BPH) in older men can cause lower urinary tract symptoms (LUTS), which are increasingly managed with medications. Frailty may contribute to both symptom progression and serious adverse events (SAEs), shifting the balance of benefits and harms of drug therapy. Objective: To assess the association between a deficit accumulation frailty index and clinical BPH progression or SAE. Design, Setting, and Participants: This cohort study used data from the Medical Therapy of Prostatic Symptoms trial, which compared placebo, doxazosin, finasteride, and combination therapy in men with moderate-to-severe LUTS, reduced urinary flow rate, and no prior BPH interventions, hypotension, or elevated prostate-specific antigen. Enrollment was from 1995 to 1998, and follow-up was through 2001. Data were assessed in February 2021. Exposures: A frailty index (score range, 0-1) using 68 potential deficits collected at baseline was used to categorized men as robust (score ≤0.1), prefrail (score 0.1 to <0.25), or frail (score ≥0.25). Main Outcomes and Measures: Primary outcomes were time to clinical BPH progression and time to SAE, as defined in the parent trial. Adjusted hazard ratios (AHRs) were estimated using Cox proportional hazards regressions adjusted for demographic variables, treatment group, measures of obstruction, and comorbidities. Results: Among 3047 men (mean [SD] age, 62.6 [7.3] years; range, 50-89 years) in this analysis, 745 (24%) were robust, 1824 (60%) were prefrail, and 478 (16%) were frail at baseline. Compared with robust men, frail men were older (age ≥75 years, 12 men [2%] vs 62 men [13%]), less likely to be White (646 men [87%] vs 344 men [72%]), less likely to be married (599 men [80%] vs 342 men [72%]), and less likely to have 16 years or more of education (471 men [63%] vs 150 men [31%]). During mean (SD) follow-up of 4.0 (1.5) years, the incidence rate of clinical BPH progression was 2.2 events per 100 person-years among robust men, 2.9 events per 100 person-years among prefrail men (AHR, 1.36; 95% CI, 1.02-1.83), and 4.0 events per 100 person-years among frail men (AHR, 1.82; 95% CI, 1.24-2.67; linear P = .005). Larger point estimates were seen among men who received doxazosin or combination therapy, although the test for interaction between frailty index and treatment group did not reach statistical significance (P for interaction = .06). Risk of SAE was higher among prefrail and frail men (prefrail vs robust AHR, 1.81; 95% CI, 1.48-2.23; frail vs robust AHR, 2.86; 95% CI, 2.21-3.69; linear P < .001); this association was similar across treatment groups (P for interaction = .76). Conclusions and Relevance: These findings suggest that frailty is independently associated with greater risk of both clinical BPH progression and SAEs. Older frail men with BPH considering initiation of drug therapy should be counseled regarding their higher risk of progression despite combination therapy and their likelihood of experiencing SAEs regardless of treatment choice.

Comparative Outcomes for Pelvic Organ Prolapse Surgery among Nursing Home Residents and Matched Community Dwelling Older Adults.

PURPOSE: We compared short and long-term outcomes between nursing home residents and matched community dwelling older adults undergoing surgery for pelvic organ prolapse. MATERIALS AND METHODS: This retrospective cohort study evaluates women 65 years old or older undergoing different types of pelvic organ prolapse repairs (anterior/posterior, apical and colpocleisis) between 2007 and 2012 using Medicare claims and the Minimum Data Set for Nursing Home Residents. Long-stay nursing home residents were identified and propensity score matched (1:2) to community dwelling older individuals based on procedure type, age, race and Charlson score. Generalized estimating equation models were created to determine the relative risk of hospital length of stay 3 or more days, 30-day complications and 1-year mortality between the 2 groups. Kaplan-Meier curves were created comparing 1-year mortality between groups. RESULTS: There were 799 nursing home residents and 1,598 matched community dwelling older adults who underwent pelvic organ prolapse surgery and were included in our analyses. Nursing home residents demonstrated statistically significant increased risk for hospital length of stay 3 or more days (38.9% vs 18.6%, adjusted RR 2.1, 95% CI 1.8-2.4), 30-day complications (15.1% vs 3.8%, aRR 3.9, 95% CI 2.9-5.3) and 1-year mortality (11.1% vs 3.2%, aRR 3.5, 95% CI 2.5-4.8) compared to community dwelling older adults. Kaplan-Meier curves illustrated similar survival findings at 1 year (11.1%, 95% CI 9.0-13.3 vs 3.2%, 95% CI 2.3-4.1, p <0.0001). CONCLUSIONS: Despite matching on several characteristics, nursing home residents demonstrated worse short and long-term outcomes compared to community dwelling older adults, suggesting other key vulnerabilities exist that contribute additional surgical risk in this population.

Time Spent Away from Home in the Year Following High-Risk Cancer Surgery in Older Adults.

OBJECTIVES: To understand where older adults spend time (at home, in the hospital, or in a nursing home) in the year following high-risk cancer surgery. DESIGN: Retrospective cohort study. SETTING: Medicare beneficiaries using data from Medicare Inpatient claims to ascertain hospital days and the Minimum Data Set to ascertain nursing home days. PARTICIPANTS: Beneficiaries who underwent high-risk cancer surgery (cystectomy, pancreaticoduodenectomy, gastrectomy, or esophagectomy) were identified to determine cumulative time spent away from home in the year following surgery. MEASUREMENTS: Adjusted percentages of time spent away from home (ie, days in a hospital or nursing home) were modeled for the year following surgery. RESULTS: A total of 37 748 beneficiaries underwent high-risk cancer surgery during the study period, and 28.3% died within 1 year. Overall, beneficiaries spent 13.9 ± 26.2 days in the hospital (over 1.5 ± 2.0 hospital readmissions) and 37.2 ± 50.6 days in the nursing home (over 1.5 ± 1.0 admissions) in the year following surgery. Among beneficiaries who were alive and dead at 1 year, 18.5% and 30.1% of time was spent away from home, respectively. Beneficiaries who were initially discharged to a facility following surgery and died within 1 year spent 44.4% of their final year away from home. CONCLUSION: Time spent away from home in the hospital and/or nursing home in the year following high-risk cancer surgery is substantial among Medicare beneficiaries. This information is crucial in counseling patients on postoperative expectations and may additionally influence preoperative decision making. J Am Geriatr Soc 68:505-510, 2020.

"A National Study Demonstrating the Need for Improved Frailty Indices for Preoperative Risk Assessment of Common Urologic Procedures".

OBJECTIVE: To compare the associations between frailty indices and postoperative complications among older adults undergoing common urologic procedures. Frailty is known to be strongly associated with poor postoperative complications; however, the optimal way to measure frailty remains unknown. METHODS: We identified the 20 most common urologic procedures from 2013-2016 in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Frailty was measured using the NSQIP frailty index, simplified frailty index, and Risk Analysis Index. Multivariable logistic regression models were performed with each index and the American Society of Anesthesiologists (ASA) classification system with postoperative complications (any, major, or minor) as the outcomes. Statistical models were compared using the following fit parameters: area under the curve, Akaike information criterion, and Bayesian information criterion. RESULTS: A total of 158,855 procedures were identified. All frailty indices (NSQIP frailty index, simplified frailty index, and Risk Analysis Index) and ASA were associated with increased odds for any, major, and minor complications (all P values <.001). ASA demonstrated stronger model fit parameters for any, major and minor complications compared to all other indices, with an area under the curve of 0.63, 0.64, and 0.64, respectively (all P values <.001). Adding ASA to each frailty index resulted in slight improvement of model fit parameters (P value <.001). CONCLUSION: ASA slightly outperforms current frailty indices in predicting postoperative complications among individuals undergoing commonly performed urologic procedures. Our findings highlight the need for improved frailty measures for preoperative risk assessment.

Factors Associated with Regional Adoption of Ureteroscopy in California from 2005 to 2016.

PURPOSE: To explore regional adoption of ureteroscopy (URS) over extracorporeal shockwave lithotripsy (SWL) in the state of California (CA) and to identify factors associated with this adoption over time. MATERIALS AND METHODS: We used the California Office of Statewide Health Planning and Development (OSHPD) public data to identify URS and SWL procedures performed for renal and ureteral stones from 2005 to 2016. The level of analysis was the region wherein each procedure was performed, defined by the 19 CA labor market regions. OSHPD data were supplemented with the Area Health Resource File to provide information on regional characteristics. Generalized linear regression was used to determine procedural rates adjusted for age, gender and race. Choropleth time series maps were used to illustrate adoption of URS by region over time. RESULTS: A total of 328,795 URS and SWL procedures were identified from 2005 to 2016. The number of URS procedures surpassed the number of SWL procedures in 2011. Fourteen regions became URS predominant by 2016 and were characterized as having a higher per capita income, higher percentages with a college education and lower percentage of female heads-of-household (all p-values <0.05). A higher percentage of patients in these regions were male and had private or Medicare insurance (p = 0.03 for both). CONCLUSIONS: From 2005 to 2016, most CA regions adopted URS as the primary renal and ureteral stone management strategy. These regions demonstrated characteristics of higher socioeconomic status compared to regions that remained SWL predominant. A better understanding of such differences in practice patterns will allow urologists to better negotiate for the capital expenditures required to conform to evolving standards of care and allow patients the ability to make more informed decisions on where they receive care.

Incidence and Management of Uncomplicated Recurrent Urinary Tract Infections in a National Sample of Women in the United States.

OBJECTIVE: To determine the incidence and characteristics of women with uncomplicated recurrent urinary tract infections (UTIs) and to explore whether the use of culture-driven treatment affects rates of UTI-related complications and resource utilization. MATERIALS AND METHODS: Using MarketScan claims from 2003 to 2011, we identified UTI-naive women ages 18-64 with incident-uncomplicated recurrent UTIs. Recurrent UTIs were defined as 3 UTI visits associated with antibiotics during a 12-month period. Cases were excluded if they had a UTI in the preceding year, or if they had any complicating factors (eg, abnormality of the urinary tract, neurologic condition, pregnancy, diabetes, or currently taking immunosuppression). We next assessed use of urine cultures, imaging, and cystoscopy, and performed propensity score matching with logistic regression to determine whether having a urine culture associated with >50% of UTIs affected rates of complications and downstream resource utilization. RESULTS: We identified 48,283 women with incident-uncomplicated recurrent UTIs, accounting for an overall incidence of 102 per 100,000 women, highest among women ages 18-34 and 55-64. Sixty-one percent of these women had at least 1 urine culture, 6.9% had imaging, and 2.8% had cystoscopy. Having a urine culture >50% of the time was associated with fewer UTI-related hospitalizations and lower rates of intravenous antibiotic use, whereas demonstrating higher rates of UTI-related office visits and pyelonephritis. CONCLUSION: The incidence of uncomplicated recurrent UTIs increases with age. Urine culture-directed care is beneficial in reducing high-cost services including UTI-related hospitalizations and intravenous antibiotic use, making urine cultures a valuable component to management of these patients.

Validation of a Medicare Claims-based Algorithm for Identifying Freestanding Ambulatory Surgery Centers.

BACKGROUND AND OBJECTIVE: With visits to ambulatory surgery centers (ASCs) on the rise, accountability in the care provided by these facilities and the surgeons who staff them is required. This requires the ability to measure and monitor ASC-based care over time. For this reason, we developed and validated a claims-based algorithm to identify ASCs. RESEARCH DESIGN: Using a 20% sample of Medicare claims (2002-2008), we developed 3 ASC definitions. Definition 1 identified unique facilities with tax identification numbers and appropriate Place of Service and Type of Service codes. Definition 2 had the same conditions but also required specific Specialty codes. Definition 3 involved a multistep cleansing stage, in which facilities with indeterminate information in the fields of interest were eliminated. We assessed agreement between these definitions and findings from alternative data sources. RESULTS: Placing additional requirements on how a freestanding ASC was defined within Medicare claims helped in the refinement of our algorithm. Agreement on the number of unique ASCs in Florida over the study interval was greatest between Definition 3 and the State Ambulatory Surgery Databases (concordance correlation coefficient=0.984; 95%, confidence interval, 0.967-0.992). With the Provider of Services Extract serving as the reference standard, our algorithm (based on Definition 3) had a positive predictive value of 99.0% (95% confidence interval, 98.6%-99.4%) for determining health care markets that experienced the opening of an ASC. CONCLUSIONS: The consequent inference is that our algorithm represents an accurate tool for distinguishing and tracking ASCs in Medicare data.

Physician Use of Sacral Neuromodulation Among Medicare Beneficiaries With Overactive Bladder and Urinary Retention.

OBJECTIVE: To identify physician-level factors associated with high rates of sacral neuromodulation testing. MATERIALS AND METHODS: We performed a retrospective cohort study using a 20% sample of national Medicare claims to identify physicians who performed sacral neuromodulation procedures between 2005 and 2010. Physician-level rates of device testing were determined based on the number of patients seen for overactive bladder and urinary retention diagnoses in the office in each calendar year. These rates were then used to fit a Poisson model to examine factors associated with high rates of device testing. RESULTS: The number of physicians performing test procedures increased 4-fold from 2005 to 2010. Average rates of test procedures increased from 4.0 to 6.4 procedures per physician per year (P <.001), whereas rates of device implantation remained stable (P = .23). Physicians who had higher rates of device testing were associated with lower rates of device implantation (estimate, -1.76, P <.01). Other predictors of physicians with higher test rates included more recent calendar year, testing done in any setting other than an ambulatory surgery center, gynecology subspecialty, and geographic location in the South and West (all P values <.01). CONCLUSION: Over time, physicians are testing more patients but are not implanting more devices. Additionally, there is an inverse relationship between rates of device testing and implantation, suggesting opportunities to improve efficiency and resource utilization.

Ambulatory Surgery Centers and Their Intended Effects on Outpatient Surgery.

OBJECTIVES: To assess the impact of ambulatory surgery centers (ASCs) on rates of hospital-based outpatient procedures and adverse events. DATA SOURCES: Twenty percent national sample of Medicare beneficiaries. STUDY DESIGN: A retrospective study of beneficiaries undergoing outpatient surgery between 2001 and 2010. Health care markets were sorted into three groups-those with ASCs, those without ASCs, and those where one opened for the first time. Generalized linear mixed models were used to assess the impact of ASC opening on rates of hospital-based outpatient surgery, perioperative mortality, and hospital admission. PRINCIPAL FINDINGS: Adjusted hospital-based outpatient surgery rates declined by 7 percent, or from 2,333 to 2,163 procedures per 10,000 beneficiaries, in markets where an ASC opened for the first time (p < .001 for test between slopes). Within these markets, procedure use at ASCs outpaced the decline observed in the hospital setting. Perioperative mortality and admission rates remained flat after ASC opening (both p > .4 for test between slopes). CONCLUSIONS: The opening of an ASC in a Hospital Service Area resulted in a decline in hospital-based outpatient surgery without increasing mortality or admission. In markets where facilities opened, procedure growth at ASCs was greater than the decline in outpatient surgery use at their respective hospitals.

Understanding the diffusion of ambulatory surgery centers.

BACKGROUND: Outpatient surgery is increasingly delivered at freestanding ambulatory surgery centers (ASCs), which are thought to deliver quality care at lower costs per episode. The objective of this study was to understand potential facilitators and/or barriers to the introduction of freestanding ASCs in the United States. METHODS: This is an observational study conducted from 2008 to 2010 using a 20% sample of Medicare claims. Potential determinants of ASC dissemination, including population, system, and legal factors, were compared between markets that always had ASCs, never had ASCs, and those that had new ASCs open during the study. Multivariable logistic regression was used to determine characteristics of markets associated with the opening of a new facility in a previously naïve market. RESULTS: New ASCs opened in 67 previously naïve markets between 2008 and 2010. ASCs were more likely to open in hospital service areas that were urban (adjusted odds ratio [OR], 4.10; 95% confidence interval [CI], 1.51-10.96), had higher per capita income (adjusted OR, 3.83; 95% CI, 1.43-10.45), and had less competition for outpatient surgery (adjusted OR, 2.13; 95% CI, 1.02-4.45). Legal considerations and latent need, as measured by case volumes of hospital-based outpatient surgery in 2007, were not associated with the opening of a new ASC. CONCLUSIONS: Freestanding ASCs opened in advantageous socioeconomic environments with the least amount of competition. Because of their associated efficiency advantages, policy makers might consider strategies to promote ASC diffusion in disadvantaged markets to potentially improve access and reduce costs.

Ambulatory surgery centers and outpatient procedure use among Medicare beneficiaries.

BACKGROUND: There has been a strong push to move outpatient surgery from hospital settings to ambulatory surgery centers (ASCs). Despite the efficiency advantages of ASCs, many are concerned that these facilities could increase overall utilization. OBJECTIVE: To assess the impact of ASC opening on rates of outpatient surgery. DESIGN: This was a retrospective cohort study of Medicare beneficiaries undergoing outpatient surgery between 2001 and 2010. We compared population-based rates of outpatient surgery in Hospital Service Areas (HSAs) with freestanding ASCs to those without. After adjusting for differences using multiple propensity score methods, we assessed the impact of ASC opening in an HSA previously without one on rates of outpatient surgery. SUBJECTS: Patients included were Medicare beneficiaries with Part B eligibility. MAIN OUTCOME MEASURE: Adjusted HSA-level rates of outpatient surgery. RESULTS: Adjusted outpatient surgery rates increased from 2806 to 3940 per 10,000 and the number of ASC operating rooms grew from 7036 to 11,223 (both P<0.001 for trend). By the fourth year after opening, rates of outpatient surgery increased by 10.9% (from 3338 to 3701 per 10,000) in HSAs adding an ASC for the first time. In contrast, outpatient surgery rates grew by only 2.4% and 0.6% in HSAs where an ASC was always or never present, respectively (P<0.001 for test between 3 slopes). CONCLUSIONS: Rather than redistributing patients from one setting to another, the opening of ASCs increases outpatient surgery use. However, the 10.9% increase is more modest than previously suggested by state-level data.

Ambulatory surgery centers and outpatient urologic surgery among Medicare beneficiaries.

OBJECTIVE: To determine the effect of an ambulatory surgery center (ASC) opening in a healthcare market on utilization and quality of outpatient urologic surgery. METHODS: This is a retrospective cohort study of Medicare beneficiaries undergoing outpatient urologic surgery from 2001 to 2010. Markets were classified into 3 groups based on ASC status (ie, those with ASCs, those without ASCs, and those where ASCs were introduced). Multiple propensity score methods adjusted for differences between markets and general linear mixed models determined the effect of ASC opening on utilization and quality, defined by mortality and hospital admission within 30 days of the index procedure. RESULTS: During the study period, 195 ASCs opened in markets previously without one. Rates of hospital-based urologic surgery in markets where ASCs were introduced declined from 221 to 214 procedures per 10,000 beneficiaries in the 4 years after baseline. In contrast, rates in the other 2 market types increased over the same period (P<.001). Rates of outpatient urologic surgery overall (ie, in the hospital and ASC) demonstrated similar growth across market types during same period (P=.56). The introduction of an ASC into a market was not associated with increases in hospital admission or mortality (P>.5). CONCLUSION: The introduction of an ASC into a healthcare market lowered rates of outpatient urologic surgery performed in the more expensive hospital setting. This redistribution was not associated with declines in quality or with greater growth in overall outpatient surgery use.

Affordable Care Act: implications in female pelvic medicine and reconstructive surgery.

The Patient Protection and Affordable Care Act (PPACA) of 2010 marks an important milestone in redefining how healthcare will be practiced in the United States for decades to come. This review article will outline the basic concepts associated with the PPACA, including value-based purchasing, pay for performance, accountable care organizations, bundled payments, and patient-centered medical homes, and will discuss how each of these components of the PPACA will impact the subspecialty of Female Pelvic Medicine and Reconstructive Surgery (FPMRS).

Effectiveness of mesh compared with nonmesh sling surgery in Medicare beneficiaries.

OBJECTIVE: To assess the effectiveness of mesh compared with nonmesh slings placed in different surgical settings as measured by the frequency of complications within 1 year. METHODS: We performed a retrospective cohort study of Medicare beneficiaries undergoing sling surgery from 2006 to 2008 in hospital outpatient departments and hospital-based ambulatory surgery centers. Slings were identified and categorized according to the use of mesh by Healthcare Common Procedure Coding System codes and temporary "C" Healthcare Common Procedure Coding System codes. Patients were followed for 1 year after each procedure to identify complications. Logistic models were fit to assess relationships among sling type, surgical setting, and various complications. RESULTS: We identified 6,698 Medicare beneficiaries who underwent mesh sling procedures and 445 Medicare beneficiaries who underwent nonmesh sling procedures. The overall frequency of complications was similar between the two groups at 69.8% and 72.6% in the mesh and nonmesh groups, respectively (P=.22). Infectious complications were the most common complication at 45.4% and 50.1% of the mesh and nonmesh groups, respectively (P=.06). Patients undergoing mesh procedures were less likely than patients undergoing nonmesh procedures to require management for bladder outlet obstruction (13.9% compared with 19.3%, adjusted odds ratio [OR] 0.66, 95% confidence interval [CI] 0.52-0.85) and were less likely to have a subsequent sling removal and revision or urethrolysis (2.7% compared with 4.7%, adjusted OR 0.56, 95% CI 0.35-0.89). CONCLUSION: Frequencies of most complications were similar regardless of the use of mesh except for the management of bladder outlet obstruction. These results did not differ based on the surgical setting where the sling procedure was performed. LEVEL OF EVIDENCE: II.

Differential adoption of laser prostatectomy for treatment of benign prostatic hyperplasia.

OBJECTIVE: To evaluate whether socioeconomic environment affects the adoption of new laser technology for treatment of benign prostatic hyperplasia (BPH). METHODS: Using all payer data, we identified all discharges for laser prostatectomy or transurethral resection of the prostate (TURP) performed in Florida (2001-2009). We determined whether or not each of 114 healthcare markets (Hospital Service Areas) offered laser prostatectomy or TURP and assessed the market-level socioeconomic environment using a previously described ZIP code-based summary score. We used generalized estimating equations to examine the association of socioeconomic environment with offering laser prostatectomy or TURP, adjusting for additional market characteristics. RESULTS: Better socioeconomic environment was associated with offering laser prostatectomy (odds ratio 1.21 for each 1 point increase in summary score, 95% confidence interval 1.08-1.35, P <.001). Adoption of laser prostatectomy over time was more rapid in markets with superior socioeconomic environment (P <.001 for interaction of socioeconomic summary score with year), such that by study midpoint, 82% of advantaged vs 54% of disadvantaged markets had adopted this new technology. In contrast, socioeconomic environment had only minimal effects on whether or not a market offered TURP. CONCLUSION: We found delayed access to new laser technology in more disadvantaged socioeconomic environments, which may translate into disparities in certain outcomes after transurethral surgery for BPH.