Simplification of the Fuhrman grading system for renal cell carcinoma.

INTRODUCTION: The Fuhrman grading system (FGS) is the most widely utilized pathological classification and predictor of renal cell carcinoma (RCC) prognosis. The aim of this study was to test the prognostic ability of a simplified two-tier FGS. MATERIALS AND METHODS: We reviewed the data of 509 patients with clear cell RCC who underwent radical or partial nephrectomy between January 1994 and April 2007. The conventional four-tier (I, II, III, IV) FGS was compared to a simplified two-tier FGS in which grades I and II were combined (low grade) and grades III and IV were combined (high grade). Cancer-specific survival (CSS) was calculated for each patient. Univariate and multivariate analyses were used in combination with area under the curve (AUC) of receiver operating characteristic curves to compare prognostic accuracies between grading schemes. RESULTS: Median follow up was 81.6 months. Using the conventional FGS, the 5 year CSS for Fuhrman grades I, II, III, and IV were 74.1%, 76.0%, 57.3%, and 40.7%, respectively (p < 0.001). Using the simplified two-tier FGS, the 5 year CSS for low grade and high grade were 75.5% and 54.7%, respectively (p < 0.001). Both FGSs achieved independent predictor status in multivariate analyses. Prognostic accuracy of multivariate models between the two FGSs had nearly identical AUCs, with a c-statistic of 0.769 and 0.716 for the two-tier and conventional systems, respectively. CONCLUSIONS: Our findings indicate that the simplified FGS performs similarly to the conventional system. The use of this simplified system may promote greater continuity of pathological interpretation as well as provide a more simplified approach for clinician utilization.

The influence of socioeconomic factors on gender disparities in lower extremity bypass.

BACKGROUND: Some contend that gender differences in outcomes after lower extremity bypass (LEB) for peripheral arterial disease (PAD) relate to socioeconomic factors (SEFs). Here, we evaluate these disparities with attention to clinically relevant yet understudied SEF. METHODS: A retrospective cohort study of patients aged >50 y with PAD undergoing LEB was performed using data from Pennsylvania Health care and Cost Containment Council (2003-2011). Multivariable logistic regression modeling was performed to evaluate the association between gender and outcomes with adjustment for potential confounders including SEF such as income, insurance provider, distance to hospital, and race. Generalized estimating equations were used to adjust for hospital clustering. Independent models were developed to examine death or serious morbidity (DSM) and failure-to-rescue (FTR). RESULTS: Of 4202 patients identified, 1510 (36%) were women. SEF differed by gender. DSM was more frequent in women (15.6% versus 12.2%; P = 0.002). There was no association between gender and FTR in univariate analysis (P = 0.49). SEFs were associated with DSM and FTR. After adjustment for potential confounders including SEF, women remained more likely to experience DSM (odds ratio = 1.28; P = 0.01). There remained no significant association between gender and FTR on independent modeling (odds ratio = 0.49; P = 0.11). CONCLUSIONS: Women undergoing LEB in the state of Pennsylvania are at increased risk of poor outcomes, which is not completely explained by SEF. Quality of postoperative care does not appear to be different between gender as there was no difference in FTR. To improve these outcomes, efforts should be made to increase awareness of PAD and promote screening among high-risk women to ensure timely diagnosis and referral.

The effect of colorectal cancer screening mandates on access to care and clinical outcomes: a retrospective study of patients undergoing operations of the colon and rectum.

INTRODUCTION: Policies that mandate colorectal screening coverage by private insurers are associated with increased use of screening procedures. We seek to understand whether such mandates have improved access to care and short-term operative outcomes for patients undergoing operations of the colon and rectum (OCR). METHODS: Privately insured OCR patients, ages 50-64, enrolled in the Nationwide Inpatient Sample (NIS) (2000-2009) were identified. Patients were classified as "exposed" if they underwent OCR in a state that implemented a mandate ≥ 2 years before their procedure. Three outcomes were examined: admission source, postoperative complications, and postoperative mortality. Univariate analyses were performed by the use of logistic regression models. Multivariable logistic regression models were developed to evaluate the relationship between exposure status, admission source, postoperative complications, and postoperative mortality, with adjustment for confounders. RESULTS: We identified 99,405 patients who underwent OCR during the study period. Of these patients, 39% were "exposed," 23% were admitted from the ED, 32% developed a postoperative complication, and 2% died during the admission. After adjusting for confounders, exposed patients were less likely to access OCR through the emergency department (odds ratio 0.87; 95% confidence interval 0.83-0.91) and less likely to develop postoperative complications (odds ratio 0.94; 95% confidence interval 0.89-0.98). There was no detectable difference in postoperative mortality. CONCLUSION: Implementation of policies mandating coverage of colorectal screening modestly reduced emergent admission for OCR among privately insured patients. Additional studies are required to examine the screening status of patients to determine causality. Remaining states should consider implementing similar policies.