Value-based care for the treatment and evaluation of benign prostatic hyperplasia: an analysis of a metropolitan service area claims database.

PURPOSE: With an aging population, cost containment and improved outcomes will be crucial for a sustainable healthcare ecosystem. Current data demonstrate great variation in payments for procedures and diagnostic workup of benign prostatic hyperplasia (BPH). To help determine the best financial value in BPH care, we sought to analyze the major drivers of total payments in BPH. MATERIALS AND METHODS: Commercial and Medicare claims from the Truven Health Analytics Markestscan® database for the Austin, Texas Metropolitan Service Area from 2012 to 2014 were queried for encounters with diagnosis and procedural codes related to BPH. Linear regression was utilized to assess factors related to BPH-related payments. Payments were then compared between surgical patients and patients managed with medication alone. RESULTS: Major drivers of total payments in BPH care were operative, namely transurethral resection of prostate (TURP) [$2778, 95% CI ($2385-$3171), p < 0.001) and photoselective vaporization (PVP) ($3315, 95% CI ($2781-$3849) p < 0.001). Most office procedures were also associated with significantly higher payments, including cystoscopy [$708, 95% CI ($417-$999), p < 0.001], uroflometry [$446, 95% CI ($225-668), p < 0.001], urinalysis [$167, 95% CI ($32-$302), p = 0.02], postvoid residual (PVR) [$245, 95% CI ($83-$407), p < 0.001], and urodynamics [$1251, 95% CI ($405-2097), p < 0.001]. Patients who had surgery had lower payments for their medications compared to patients who had no surgery [$120 (IQR: $0, $550) vs. $532 (IQR: $231, $1852), respectively, p < 0.001]. CONCLUSION: Surgery and office-based procedures are associated with increased payments for BPH treatment. Although payments for surgery were more in total, surgical patients paid significantly less for BPH medications.

International and Multi-institutional Assessment of Factors Associated With Performance and Quality of Lymph Node Dissection During Radical Nephrectomy.

OBJECTIVE: To determine factors associated with performance and quality of lymph node dissection during radical nephrectomy. MATERIALS AND METHODS: Using an International Data Registry, we performed multilevel logistic regression to determine the association of surgical approach (open surgery vs minimally invasive surgery), institutional experience (low, moderate, and high tertiles), and institutional preference (minimally invasive surgery, balanced, and open surgery tertiles) with the performance of lymph node dissection in subgroups by clinical stage and nodal status. RESULTS: Among 1,742 patients undergoing radical nephrectomy, 312 (18%) underwent lymph node dissection, which was associated with stage (28% for ≥cT2 vs 9.3% for cT1), and nodal status (68% for ≥cN1 vs 13% for cN0). Open surgery was significantly associated with performing lymph node dissection in all subgroups. Institutional experience and institutional preference had no association with performing lymph node dissection in the ≥cN1 group. The number of nodes removed was greater for open surgery (mean 5.9) vs minimally invasive surgery (mean 3.4); this held true even when stratified by stage and nodal status. CONCLUSION: In this large dataset, open surgical radical nephrectomy is associated with more frequent performance and higher quality of lymph node dissection, which may owe to selection bias but also could reflect technical concerns. In the patient population in whom lymph node dissection is recommended (≥cN1), this is not explained by institutional experience or preference. Lymph node dissection may be under-utilized for ≥cN1 disease and over-utilized for cN0 disease, at least according to practice guidelines.

Cost Analysis of Treatments for Ureteropelvic Junction Obstruction.

BACKGROUND AND PURPOSE: Ureteropelvic junction obstruction is a common urologic condition that accounts for approximately $12 million in inpatient spending annually. Few studies have assessed the costs related to treatment. We sought to examine the cost of care for patients treated for ureteropelvic junction obstruction. PATIENTS AND METHODS: We used the MarketScan® database to identify adults from 18 to 64 years old treated with minimally invasive pyeloplasty, open pyeloplasty, and endopyelotomy for ureteropelvic junction obstruction between 2002 and 2010. Our primary outcome was total expenditures related to the surgical episode, defined as the period from 30 days prior until 30 days after the index surgery. We fit a multinomial linear regression model to evaluate cost of the surgical episode, adjusting for age, gender, comorbidity, benefit plan type, and region of residence. RESULTS: We identified 1251 endopyelotomies, 717 open pyeloplasties, and 1048 minimally invasive pyeloplasties. The adjusted mean costs were $16,379 for endopyelotomy, $22,421 for open pyeloplasty, and $22,843 for minimally invasive pyeloplasty (p < 0.0001, ANCOVA). Both open and minimally invasive pyeloplasties were more costly than endopyelotomy (both p < 0.0001, comparison between groups). However, the cost of open and minimally invasive pyeloplasties was similar (p = 0.57, comparison between groups). CONCLUSIONS: Among the three treatments, endopyelotomy was the least expensive in the immediate perioperative period. Open and minimally invasive pyeloplasties were similar in cost, but both more expensive than endopyelotomies. The similar cost between the two pyeloplasty approaches provides additional evidence that minimally invasive pyeloplasty should be considered the standard treatment for ureteropelvic junction obstruction.

Expulsive therapy versus early endoscopic stone removal in patients with acute renal colic: a comparison of indirect costs.

PURPOSE: While medical expulsive therapy is associated with lower health care expenditures compared to early endoscopic stone removal in patients with renal colic, little is known about the effect of medical expulsive therapy on indirect costs. MATERIALS AND METHODS: Using a previously validated claims based algorithm we identified a cohort of patients with acute renal colic. After determining the up-front treatment type (ie an initial course of medical expulsive therapy vs early endoscopic stone removal) we compared differences in rates of short-term disability filing. We used propensity score matching to account for differences between treatment groups such that patients treated with medical expulsive therapy vs early endoscopic stone removal were similar with regard to measured characteristics. RESULTS: In total, 257 (35.8%) and 461 (64.2%) patients were treated with medical expulsive therapy or early endoscopic stone removal, respectively. There were no differences between treatment groups after propensity score matching. In the matched cohort the patients treated with medical expulsive therapy had a 6% predicted probability of filing a claim for short-term disability compared to 16.5% in the early endoscopic stone removal cohort (p <0.0001). Among the patients who filed for short-term disability those prescribed medical expulsive therapy had on average 1 fewer day of disability than those treated surgically (0.9 vs 1.8 days, p <0.001). CONCLUSIONS: An initial trial of medical expulsive therapy is associated with significantly lower indirect costs to the patient compared to early endoscopic stone removal. These findings have implications for providers when counseling patients with acute renal colic.

Population level assessment of hospital based outcomes following laparoscopic versus open partial nephrectomy during the adoption of minimally invasive surgery.

PURPOSE: The comparative outcomes of laparoscopic and open partial nephrectomy remain incompletely defined. Therefore, we used population based data to examine resource use and short-term outcomes among patients with kidney cancer treated with laparoscopic vs open partial nephrectomy. MATERIALS AND METHODS: Using linked SEER (Surveillance, Epidemiology, and End Results)-Medicare data we identified patients with kidney cancer treated with laparoscopic or open partial nephrectomy from 2000 through 2007. We then used Medicare claims to identify several postoperative outcomes including intensive care unit care, length of stay, rehospitalizations, operative mortality and postoperative complications. We fit multivariate logistic regression models to estimate the association between each outcome and surgical approach (ie laparoscopic partial nephrectomy vs open partial nephrectomy), adjusting for patient and tumor characteristics. RESULTS: We identified 651 (28%) and 1,670 (72%) patients treated with laparoscopic partial nephrectomy and open partial nephrectomy, respectively. Compared to those who underwent open partial nephrectomy, patients treated with laparoscopic partial nephrectomy had a 34% lower probability of requiring intensive care unit time (20.0% vs 30.2%, p <0.001) and shorter median length of stay (3 vs 5 days, p <0.001), with no differences observed in the likelihood of rehospitalization or operative mortality. While the frequency of postoperative complications was similar (35.5% vs 36.1%, p = 0.829), patients treated with laparoscopic partial nephrectomy had a nearly twofold greater probability of genitourinary complications and postoperative hemorrhage (p <0.001). CONCLUSIONS: At a population level the patients with kidney cancer treated with laparoscopic partial nephrectomy experienced a shorter and less intense hospitalization, supporting the benefits of laparoscopy. However, the greater likelihood of procedure related complications highlights the need for continued efforts aimed at ensuring the safe adoption and application of this advanced surgical technique.

Medical expulsive therapy versus early endoscopic stone removal for acute renal colic: an instrumental variable analysis.

PURPOSE: The use of medical expulsive therapy to hasten stone passage potentially decreases expenditures around episodes of renal colic. However, these efficiency gains may be mitigated if patients treated with medical expulsive therapy have frequent health care encounters due to pain while waiting for the stones to pass. MATERIALS AND METHODS: Using claims data (2002 to 2006) we identified adult men with acute renal colic. We compared 6-week payments as well as frequency of hospitalization and emergency department revisits associated with an initial course of medical expulsive therapy with those for early endoscopic stone removal. To account for unmeasured confounding we performed an instrumental variable analysis, exploiting variation in recommended treatments based on the day of the week that a patient's first emergency department visit occurred. RESULTS: Overall 1,835 and 4,397 men underwent medical expulsive therapy or early endoscopic stone removal, respectively. Although minimal differences existed between men with respect to the day of the week of emergency department presentation, weekend encounters were strongly associated with receiving medical expulsive therapy (p <0.001). Two-stage least squares regression revealed 6-week payments to be tenfold lower for men on medical expulsive therapy who were candidates for either treatment (p <0.001). While there was no difference in frequency of hospitalization, these men were more likely to have a repeat emergency department visit compared to those who underwent endoscopic stone removal (68.8% vs 39.6%, respectively, p = 0.025). CONCLUSIONS: Findings on medical expulsive therapy are mixed, with lower 6-week payments but more frequent repeat emergency department visits. These data inform patients who are candidates for medical expulsive therapy or endoscopic stone removal when making decisions about their care.

Use of ureteroscopy before and after expansion of lithotripter ownership in Michigan.

OBJECTIVE: To determine whether ureteroscopy (URS) rates decreased following the expansion of lithotripter ownership in Michigan. Historically, Michigan has had limited urologist investment in lithotripters owing to strict Certificate of Need legislation. However, 2 of the nation's largest lithotripsy providers formed Michigan subsidiaries in 2005 and 2006, thereby altering the ownership landscape. Urologists who acquired partnership shares were incentivized to perform shock wave lithotripsy preferentially over URS. Because of ownership expansion, the rates of URS might have decreased. METHODS: From the Michigan files of the State Ambulatory Surgery Database, we abstracted the discharges for URS performed at hospital-based outpatient departments. We measured the differences between the patients who underwent URS in the year before (2004) and the year after (2007) ownership expansion. We then calculated the annual rates of URS in Michigan and evaluated for changes over time. RESULTS: A total of 5857 and 6294 URSs were performed in 2004 and 2007, respectively. Significant differences in age (P < .001), race (P < .001), primary payer (P < .001), and comorbidity status (P < .001) were observed between the patients who underwent URS before and after ownership expansion. However, the rates of URS in Michigan remained relatively flat despite the increased urologist ownership of lithotripters (P = .129 for the temporal trend). CONCLUSION: The introduction of physician ownership of lithotripter units in Michigan was not associated with decreased rates of URS but might have influenced treatment selection among certain patient groups.

Multi-institutional assessment of ureteroscopic laser papillotomy for chronic flank pain associated with papillary calcifications.

PURPOSE: We evaluated the long-term safety, efficacy and durability of ureteroscopic laser papillotomy for chronic flank pain associated with renal papillary calcifications. MATERIALS AND METHODS: We reviewed the medical records of all patients who underwent ureteroscopic laser papillotomy in the absence of free urinary calculi at our institutions from 1998 through 2008. Success was defined as patient report of significant pain relief. The duration of response was considered the time from papillotomy to repeat papillotomy in the same renal unit, patient report of recurrent pain or final followup. RESULTS: Ureteroscopic Ho:YAG laser papillotomy was done a total of 176 times in 65 patients, including 147 unilateral and 29 bilateral procedures. Of the patients 39 underwent multiple procedures (2 to 12). Symptomatic followup was available in 50 patients (146 procedures) during a mean of 38 months. Significantly less pain was reported after 121 procedures (83%). The mean duration of response per procedure was 26 months and 30 patients (60%) had a mean remission duration of greater than 1 year. Postoperatively hospital admission was required after 14 procedures (8%). There was no significant change in the mean estimated glomerular filtration rate during a mean 41.3-month followup. Seven of the 65 patients (11%) had hypertension before papillotomy. In 3 of the 49 patients (6.1%) with adequate followup new hypertension developed during a mean of 38 months. CONCLUSIONS: Ureteroscopic laser papillotomy is safe and effective. In patients with papillary calcifications and characteristic chronic, noncolicky pain this procedure provides significant, moderately durable symptom relief.

Medical expulsive therapy for ureteral calculi in the real world: targeted education increases use and improves patient outcome.

PURPOSE: In controlled trials medical expulsive therapy has improved outcomes in patients with ureteral stones but its real-world use and effectiveness outside a clinical trial have not been thoroughly examined. We studied the impact of targeted education of emergency department physicians about medical expulsive therapy and analyzed its impact on patient outcomes and cost. MATERIALS AND METHODS: In 2006 emergency department physicians at our institution were formally educated about medical expulsive therapy. Retrospective emergency department data were collected on patients with ureteral stones from 2003 and 2005 (before educational intervention), and 2007 (after intervention). Cost and 90-day post-emergency department event data were gathered from a health maintenance organization owned and operated by our medical center. Medical expulsive therapy prescribing trends, adverse outcome (repeat emergency department visit, hospital admission or surgery) and total cost related to ureteral calculus diagnosis were analyzed. RESULTS: Of 166 health maintenance organization patients with ureteral calculi who met all study requirements 97 (58.4%) were prescribed medical expulsive therapy and 53 (31.9%) filled the medical expulsive therapy prescription, while 113 did not. Analysis revealed a 2-fold increase in medical expulsive therapy prescribing and a 4-fold increase in prescribing alpha-blockers in each time increment. Bivariate analysis showed that the frequency of adverse outcomes was lower in the medical expulsive therapy group (37.7% vs 53.1%) and medical expulsive therapy was associated with a lower mean total cost per patient ($1,805 vs $2,372). CONCLUSIONS: Targeted educational intervention can increase the use of preferred medical expulsive therapy (alpha-blockers) in the emergency department. Medical expulsive therapy decreases the incidence of adverse events by 29% and decreases the total cost associated with ureteral stones by 24%.

Understanding the relationship between health care quality and the renal mass.

Quality is increasingly important to all stakeholders of the U.S. health care system. Endeavors to measure and improve quality have moved forward in cardiovascular disease, diabetes care, and surgical wound infections. However, in urology, such efforts have lagged. As a specialty, we are now faced with pressures, exerted primarily by payors, to roll out performance measures, or quality indicators, in the absence of science to support them. In this review, we discuss the broad concepts of health care quality and describe their relationships with small renal tumors.

Cost trends for oncological renal surgery: support for a laparoscopic standard of care.

PURPOSE: There may be inherent costs associated with the cultivation of laparoscopic expertise. We compared the cost trends for laparoscopy during the development of our program with that of open surgery for renal neoplasms. MATERIALS AND METHODS: We retrospectively reviewed the records of 381 patients treated surgically for renal cortical neoplasms from 1998 to 2003. Demographic information and cancer specific data were recorded on each subject. Direct variable costs, which are directly traceable to the patient care service provided and vary with patient volume, were used to analyze cost. Temporal trends were assessed using multivariate models developed to determine smoothed mean costs by year. RESULTS: Although it was initially more expensive, by 2003 mean costs were lower for laparoscopic than for open radical nephrectomy ($5,157 vs $5,808). This reflected a significantly lower annual increase in direct variable costs for laparoscopy vs open surgery even after adjustment for patient age, sex, race and clinical stage (p = 0.013). Although a similar trend was observed when comparing nephron sparing procedures vs open surgery, this did not attain statistical significance. In addition to surgical technique, only higher clinical stage was independently associated with increased direct variable costs after adjustment for operative year (p <0.0001). CONCLUSIONS: Relative to their open counterparts the costs of laparoscopic treatment of renal cortical neoplasms have increased at a lower rate in the last 6 years. When considered in the context of the well established benefits of laparoscopy, our findings lend additional support in favor of laparoscopy as the standard of care.

Devices for hand-assisted laparoscopic surgery.

A number of tools have been introduced to make laparoscopy easier. Some, such as 3D video systems, are interesting, and may add a modicum of benefit in some situations, but overall, have not had substantial impact. Others, such as robotic surgery, clearly have great potential, but are simply too expensive for widespread use. A few, such as the argon beam coagulator, are helpful only in particular situations. One technique has lived up to its billing and moreover, can be applied in almost any laparoscopic procedure, it is cost effective and actually does make laparoscopy easier. Hand-assisted laparoscopic surgery is a useful adjunct to the laparoscopic surgeon, and should be considered by all interested in this endeavor. This review summarizes the current hand-assistance devices and their use.