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BACKGROUND AND OBJECTIVE: It is unclear whether cytoreductive nephrectomy (CN) practices have changed in the USA after the publication of the Cancer du Rein Métastatique Nephrectomie et Antiangiogéniques (CARMENA) trial in 2018. Our primary objective is to determine the effect of the CARMENA trial on CN rates in the USA. METHODS: Patients were identified in the National Cancer Database from 2004 to 2020. A quasiexperimental difference-in-differences analysis was used to test the primary outcome, as follows: the change in CN rate was assessed among metastatic clear cell renal cell carcinoma (ccRCC) patients diagnosed before versus after 2018, while using the localized nephrectomy (LN) rate performed in the setting of nonmetastatic ccRCC as a control group. KEY FINDINGS AND LIMITATIONS: The difference-in-differences analysis identified a statistically significant decrease in CN rate after CARMENA (ß-coefficient [standard error]: -0.06 [0.025], p = 0.028), with a 10.2% absolute and a 31.8% relative rate reduction when compared with the counterfactual (expected) value (34.7% â 21.9% [actual] vs 32.1% [expected]). Primarily, relative differences in CN and LN rates before and after 2018 may be attributable to additional factors, aside from CARMENA publication, not tested in this quasiexperimental model. CONCLUSIONS AND CLINICAL IMPLICATIONS: CN rates decreased significantly after the publication of the CARMENA trial in 2018, with a minimal difference in regional or demographic practice patterns. Overall, the publication of the CARMENA trial results is seemingly associated with substantial alteration of clinical practice in the USA, with relatively broad and nonspecific adoption across facilities, regions, and demographics. PATIENT SUMMARY: For decades, the immediate surgical removal of the kidney tumor (cytoreductive nephrectomy) was a mainstay of metastatic kidney cancer treatment. In 2018, the CARMENA study showed that patients treated with systemic therapy alone had similar outcomes to patients who underwent cytoreductive nephrectomy first. In this study, we show that fewer cytoreductive nephrectomies were performed after the CARMENA trial results were published.
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Context: There is great interest in intensive primary care (IPC) interventions to address the needs of medically and socially complex patients, however it is unknown how these interventions impact patient experience. Objective: Describe the experience of patients on the Streamlined Unified Meaningfully Managed Interdisciplinary Team (SUMMIT), an IPC for patients with complex needs at a federally qualified health center serving patients with high rates of homelessness. Study Design: Qualitative study using semi-structured interviews with 25 patients enrolled in the SUMMIT intervention. We conducted a thematic analysis using a hybrid inductive/deductive approach. Results: Prior to SUMMIT, patients often felt it was difficult to engage with the healthcare system, in part due to their complex medical conditions, but also factors including prior trauma, poverty, substance use, and providers' stigma. We identified four themes related to how and why patients felt SUMMIT improved their care: 1) Investment: Patients perceived the team as truly invested in them and expressed how the team walked side by side in their care journeys to overcome stigma, low-self efficacy, and prior negative experiences with the healthcare system 2) Family: Patients reported feeling a strong sense of family with SUMMIT team members and believed that the team had genuine duty and obligation toward them, interacting with them in a non-judgmental, culturally competent manner. 3) Feeling valued: Patients expressed that the team's flexible design, continuity of team membership, care coordination and addressing unmet needs and social determinants led them to feel valued and hope. 4) Evolution of self-efficacy: Patients experienced improved self-efficacy, and were able to engage with health care proactively, instead of avoiding care. Conclusion: Medically and socially complex patients experience trauma and stigma that shape perceptions of care. Patients appreciated humanizing interactions with team members along with the additional support SUMMIT provided to overcome barriers to care. They spoke of the team as family members who valued them and they recognized how the program had helped them take a more active role in improving their own health. Our findings suggest that effectiveness of IPC interventions may lie, in part, on the use of team members who have the skills and commitment to deliver non-judgemental, culturally competent, longitudinal relationship-focused care.