Cost considerations for systemic therapy for patients with advanced genitourinary malignancies.

The rising cost of health care in the United States has been the focus of intense debate within the medical, legal, and legislative arenas, with the cost of cancer care representing an important component. Cost effectiveness is not always easy to define, and there is no standard metric in assessing this measure related to cancer therapies. Significant controversy surrounds exactly what is the appropriate cost per added year of life. This review examines cost, effectiveness, and comparative cost effectiveness of novel systemic therapies for patients with urologic malignancies. Cancer 2018;124:2897-905. © 2018 American Cancer Society.

Variation in Use of Prostate Biopsy Following Changes in Prostate Cancer Screening Guidelines.

PURPOSE: Prostate biopsy rates have paralleled decreasing prostate specific antigen screening rates since 2012. We hypothesized that biopsy rates and the change in rates since 2012 would vary considerably across hospital referral regions. MATERIALS AND METHODS: Using Medicare data from 2012 through 2014 we identified prostate biopsies performed by physicians who performed 11 or more biopsies annually. We calculated annual biopsy rates and changes in rates from 2012 to 2014 across 306 hospital referral regions. We performed multivariable regression adjusting for factors associated with annual biopsy rates (eg percent of patients older than 75 who were screened with prostate specific antigen and percent of the population that was African American). We also estimated adjusted prostate biopsy rates and changes with time across regions. RESULTS: We identified 395,993 biopsies. The overall rates decreased from 11.68 biopsies per 1,000 men in 2012 to 10.23 per 1,000 in 2014 (-12.4%, p = 0.11). Biopsy rates were higher in regions in which a greater percentage of the population was African American (ß = 0.810, 95% CI 0.235-1.384, p = 0.006), ambulatory surgical centers were available where biopsy could be performed (ß = 0.892, 95% CI 0.108-1.676, p = 0.026) and prostate specific antigen testing occurred more frequently (ß = 2.462, 95% CI 1.153-3.771, p <0.001). There was marked geographic variation in the adjusted average biopsy rate (median adjusted rate 9.08 biopsies per 1,000 men, IQR 7.65-10.76) and in the change in biopsy rates with time (median adjusted rate change -1.49 biopsies per 1,000 men, IQR -1.94--1.22 per 1,000). CONCLUSIONS: Since 2012 there has been considerable geographic variation in the performance of prostate biopsies as well as changes with time after prostate specific antigen recommendations changed. Characterizing the role of unmeasured patient and physician level factors is crucial to optimize the use and minimize the harms of prostate biopsy.

PFAS distribution in cascade derived foam at wastewater treatment plants: The role of non-linear drainage, collapse induced enrichment, and implications for removal.

Per- and polyfluorinated alkyl substances (PFAS) enrichment in foam was investigated for the first time at a wastewater treatment plant cascade. A novel sampling device was utilized to allow spatial and temporal heterogeneity in PFAS concentrations and liquid content to be characterized. Concentrations of 8 PFAS compounds were normalized to liquid content and fit to a power law model revealing strong correlation (R2 = 0.91) between drainage induced enrichment and PFAS molar volume. Short chain PFAS such as perfluorobutanoate (PFBA) exhibited minor to no enrichment factors in foam (0.24-5.9) compared to effluent concentrations across the range of foam liquid contents (0.28-6.24 %), while long chain compounds such as perfluorooctane sulfonate (PFOS) became highly enriched with factors of 295-143,000. A conceptual model is proposed to explain higher than expected enrichment of more surface-active PFAS relative to liquid content, which combines continuous partitioning of PFAS to air bubbles during foam formation with additional partitioning during non-linear drainage and foam collapse, both controlled by their affinity for the air-water interface. Scoping calculations suggest the majority of PFOS and other long chain PFAS may be removed if foam is continuously collected with potential to reduce waste volume under economic barriers for current destructive technologies.

A Dye Tracer Approach for Quantifying Fluid and Solute Flux Across the Sediment-Water Interface.

We propose a dye tracer method to characterize fluid and solute fluxes across the sediment-water interface. Zones of groundwater discharge within the streambed are first identified, and small volume slugs of 0.5 to 1 mL fluorescein dye are released at known subsurface depths. Fluorescein dye allows for visual identification of interface breakthrough locations and times, and dye concentrations at the point of discharge are recorded over time by a fluorometer to generate high resolution breakthrough curves. Groundwater velocities and dispersivities at the demonstration site are estimated by numerically fitting dye breakthroughs to the classical advection-dispersion equation, although the methodology is not limited to a specific transport model. Breakthroughs across the stream-sediment interface at the demonstration site are nonlinear with tracer release depth, and velocity estimates from breakthrough analysis are significantly more reliable than visual dye (time to first dye expression) and Darcy methods which tend to overestimate and underestimate groundwater velocity, respectively. The use of permanent injection points within the streambed and demonstrated reproducibility of dye breakthroughs allow for study of fluid and solute fluxes under seasonally varying hydrologic conditions. The proposed approach also provides a framework for field study of nonconservative, reactive solutes and allows for the determination of characteristic residence times at various depths in the streambed to better understand chemical and nutrient transformations.

Obstructing Nephrolithiasis in an 84-year-old Patient With a Diaphragmatic Herniated Ureter.

Diaphragmatic herniations of the ureter are a rare occurrence overall, with fewer than 10 cases reported. Obstructing nephrolithiasis in the setting of diaphragmatic ureteral herniation has sparsely been documented. Management options to consider include ureteroscopy and laser lithotripsy to alleviate obstruction in herniated ureters. The abnormal path of the ureter and surrounding structures pose unique risks that require careful attention and a high level of operator skill. We present imaging of an 84-year-old woman incidentally found to have right ureteral herniation through the diaphragm with an obstructing 8 mm stone in the right proximal ureter with moderate hydronephrosis.

Gaps in male infertility health services research.

The field of male infertility remains a niche specialty within urology. Although a male factor is implicated in at least 50% of all cases of infertility, and male infertility is thought to be associated with overall male health and longevity, this subspecialty comprises a relatively small proportion of urologic training. There remains a large knowledge gap with regards to prevalence of male factor infertility, as well as the need for health services for the diagnosis and treatment of male infertility. Health services research is a multidisciplinary approach that combines both qualitative and quantitative methodologies to improve patient care and outcomes pertaining to male infertility. This review summarizes the current literature pertaining to health services for male infertility and identifies opportunities for future research to improve access to and outcomes of male infertility care, including improvements in costs of care, patient education, and health policy.

Physician Reimbursement for Prostate Biopsies Falls as Procedures Shift From Offices to Facilities.

OBJECTIVE: To examine how Medicare reimbursement for prostate biopsies was allocated to physicians, ambulatory surgery centers (ASCs), and hospitals from 2012 to 2015. MATERIALS AND METHODS: Using Medicare Provider Utilization and Payment Data (2012-2015), we assessed provider payments to physicians and ASCs for transrectal ultrasound-guided prostate biopsies (Current Procedural Terminology 55700, 76842, 76972) for fee-for-service Medicare beneficiaries. Data were aggregated at provider-level for those reporting >10 biopsies per year. Hospital payments were estimated based on Outpatient Prospective Payment System. We report average and total payments for physicians, hospitals, and ASCs. RESULTS: We identified 534,807 prostate biopsies, of which 13.3% and 14.8% were associated with an ASC and hospital, respectively. Payments for all biopsies totaled $276.7 million ($152.7 million to physicians; $35.1 million to ASCs, $88.9 million to hospitals). From 2012 through 2015, physician payments for biopsies declined by $19 million (Δ=-43.2%, P = .06 for trend). Payments to ASCs (+$3.2 million, Δ = 38.8%, P = .29) and hospitals (+$11.1 million, Δ = 58.6%, P = .16) both increased. The decline in physician payments was due to a 13.7% decline in volume and lower median reimbursement for office-based procedures ($415 to $277, P = .04). The share of biopsies performed at facilities increased from 26.5% to 30.0%, and the proportion of payments associated with those settings also increased from 42.7% to 65.3%. CONCLUSION: Over time, a greater share of Medicare payments for biopsies has been directed toward facilities instead of physicians. Understanding the relationship between these trends and cancer screening and Medicare payment policies will be crucial in the future.