Meyer CP, Hanske J, Friedlander DF, Schmid M, Dahlem R, Trinh VQ, Chang SL, Kibel AS, Chun FKH, Fisch M, et al. The impact of resident involvement in male one-stage anterior urethroplasties. Urology. 2015;85 (4) :937-41.Abstract
OBJECTIVE: To assess the effect of resident involvement in male anterior urethroplasties with regard to perioperative and postoperative outcomes using a large multi-institutional prospectively collected database. METHODS: Relying on the American College of Surgeons National Surgical Quality Improvement Program Participant User Files (2005-2012), we extracted all entries with Current Procedural Terminology coding for male one-stage anterior urethroplasty in men (54,310). Cases with missing entries on resident involvement were excluded. Descriptive and logistic regression analyses were constructed to assess the impact of trainee involvement (attending only vs resident) on perioperative and postoperative outcomes. Prolonged operative time (pOT) was defined as operative time >75th percentile (>204 minutes). RESULTS: A total of 235 one-stage urethroplasties were performed during the study period, for which resident involvement was available. Resident involvement was significantly associated with younger patient age (P = .011) and patients with a pre-existing diabetic condition (P = .047). In univariate analyses, the rate of pOT was significantly higher in the resident involvement group (P = .027). In multivariate models, resident involvement was an independent predictor of pOT (odds ratio, 2.4; 95% confidence interval, 1.3-9.7; P = .035). There were no differences in 30-day postoperative complications, length of hospital stay, or readmissions. Limitations of the study include inability to adjust for case complexity and type of reconstruction. CONCLUSION: Resident involvement is associated with pOT for anterior urethral strictures. However, it does not adversely affect complication rates or the length of hospital stay.
Silverman SG, Israel GM, Trinh Q-D. Incompletely characterized incidental renal masses: emerging data support conservative management. Radiology. 2015;275 (1) :28-42.Abstract
With imaging, most incidental renal masses can be diagnosed promptly and with confidence as being either benign or malignant. For those that cannot, management recommendations can be devised on the basis of a thorough evaluation of imaging features. However, most renal masses are either too small to characterize completely or are detected initially in imaging examinations that are not designed for full evaluation of them. These masses constitute a group of masses that are considered incompletely characterized. On the basis of current published guidelines, many masses warrant additional imaging. However, while the diagnosis of renal cancer at a curable stage remains the first priority, there is the additional need to reduce unnecessary healthcare costs and radiation exposure. As such, emerging data now support foregoing additional imaging for many incompletely characterized renal masses. These data include the low risk of progression to metastases or death for small renal masses that have undergone active surveillance (including biopsy-proven cancers) and a better understanding of how specific imaging features can be used to diagnose their origins. These developments support (a) avoidance of imaging entirely for those incompletely characterized renal masses that are highly likely to be benign cysts and (b) delay of further imaging of small solid masses in selected patients. Although more evidence-based data are needed and comprehensive management algorithms have yet to be defined, these recommendations are medically appropriate and practical, while limiting the imaging of many incompletely characterized incidental renal masses.
Varda B, Sood A, Krishna N, Gandaglia G, Sammon JD, Zade J, Schmid M, Zorn KC, Trinh Q-D, Bhojani N. National rates and risk factors for stent failure after successful insertion in patients with obstructed, infected upper tract stones. Can Urol Assoc J. 2015;9 (3-4) :E164-71.Abstract
INTRODUCTION: We report the incidence of stent failure, defined as the need for salvage percutaneous nephrostomy (PCN) placement following the placement of a ureteral stent, in patients with infection of an obstructed urinary tract secondary to urolithiasis. We also sought to identify risk factors associated with ureteral stent failure. METHODS: Using the Nationwide Inpatient Sample, we used time trend analysis to examine the incidence of ureteral stent failure for infected urolithiasis, as well as the estimated annual percent change (EAPC) from 1998 to 2010. Logistic regression was performed to estimate the odds of stent failure based on patient and hospital characteristics. RESULTS: A total of 164 546 stents were placed during the study period. Of these, 97.8% resulted in successful decompression. The rates of successful stent decompression and stent failure increased over time (EAPC 14.05%, p < 0.001; EAPC 11.61%, p < 0.001). Middle-aged males with renal stones and acute kidney failure had higher odds of stent failure (p < 0.05). Salvage percutaneous nephrostomies were performed most frequently in urban teaching institutions (odds ratio [OR] 1.98, p = 0.001; OR 1.83, p < 0.001). CONCLUSIONS: Ureteral stent decompression for an infected obstructed urinary tract secondary to urolithiasis is almost always effective. For a small proportion of patients, stent failure will occur and will require the placement of a nephrostomy tube. Stent failure is associated with male gender, stone location, and renal failure. Salvage percutaneous nephrostomies for these patients occur most frequently in urban teaching hospitals. Of note, this study was limited by the presumption that coding for a PCN after stent placement indicated stent failure, which could not be verified because of the inherent limitations of the dataset.
Schmid M, Meyer CP, Trinh Q-D. The need for standardised reporting of complications. Re: Minimum 5-years follow-up of 1138 consecutive laparoscopic radical prostatectomies. BJU Int. 2015;115 (4) :501-2.
Sammon JD, Abdollah F, D'Amico A, Gettman M, Haese A, Suardi N, Vickers A, Trinh Q-D. Predicting Life Expectancy in Men Diagnosed with Prostate Cancer. Eur Urol. 2015.Abstract
CONTEXT: The widespread use of prostate-specific antigen (PSA) screening has led to the detection of more indolent prostate cancer (PCa) in healthy men. PCa treatment and screening must therefore balance the potential for life gained against the potential for harm. Fundamental to this balance is physician awareness of a patient's estimated life expectancy (LE). OBJECTIVE: To review the evidence on LE differences between men diagnosed with PCa and the general population. To examine clinician- and model-predicted LE and publicly available LE calculators. EVIDENCE ACQUISITION: A comprehensive search of the PubMed database between 1990 and September 2014 was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. Free text protocols of the following search terms were used "life expectancy prostate cancer", "life expectancy non-cancer", "non-cancer mortality prostate", and "comorbidity-adjusted life expectancy". Two internet search engines were queried daily for 1 mo for the search term "life expectancy calculator", and the top 20 results were examined. EVIDENCE SYNTHESIS: Of 992 articles and 32 websites screened, 17 articles and nine websites were selected for inclusion. Men with non-screening-detected PCa and distant disease at diagnosis were found to have shorter LE than age-matched peers, whereas men with localized PCa had prolonged LE. In general, clinician-predicted 10-yr LE was pessimistic and of limited accuracy; however, model-predicted LE provided only modest improvements in accuracy (c-index of models 0.65-0.84). Online LE calculators provide consistent LE estimates, but government life tables provide LE estimates near the mean for all calculators examined. CONCLUSIONS: The accuracy of clinician-predicted survival is limited, and while available statistical models offer improvement in discrimination, it is unclear whether they provide advantages over freely available government life tables. PATIENT SUMMARY: We examined differences in life expectancy between men diagnosed with prostate cancer and the general population, and ways of predicting life expectancy to help guide treatment decisions. We found that current models for predicting life expectancy specific to prostate cancer might not be any better than government life tables or simple rules of thumb.
Sammon JD, Pucheril D, Abdollah F, Varda B, Sood A, Bhojani N, Chang SL, Kim SP, Ruhotina N, Schmid M, et al. Preventable mortality after common urological surgery: failing to rescue?. BJU Int. 2015;115 (4) :666-74.Abstract
OBJECTIVE: To assess in-hospital mortality in patients undergoing many commonly performed urological surgeries in light of decreasing nationwide perioperative mortality over the past decade. This phenomenon has been attributed in part to a decline in 'failure to rescue' (FTR) rates, e.g. death after a complication that was potentially recognisable/preventable. PATIENTS AND METHODS: Discharges of all patients undergoing urological surgery between 1998 and 2010 were extracted from the Nationwide Inpatient Sample and assessed for overall and FTR mortality. Admission trends were assessed with linear regression. Logistic regression models fitted with generalised estimating equations were used to estimate the impact of primary predictors on over-all and FTR mortality and changes in mortality rates. RESULTS: Between 1998 and 2010, an estimated 7,725,736 urological surgeries requiring hospitalisation were performed in the USA; admissions for urological surgery decreased 0.63% per year (P = 0.008). Odds of overall mortality decreased slightly (odds ratio [OR] 0.990, 95% confidence interval [CI] 0.988-0.993), yet the odds of mortality attributable to FTR increased 5% every year (OR 1.050, 95% CI 1.038-1.062). Patient age, race, Charlson Comorbidity Index, public insurance status, as well as urban hospital location were independent predictors of FTR mortality (P < 0.001). CONCLUSION: A shift from inpatient to outpatient surgery for commonly performed urological procedures has coincided with increasing rates of FTR mortality. Older, sicker, minority group patients and those with public insurance were more likely to die after a potentially recognisable/preventable complication. These strata of high-risk individuals represent ideal targets for process improvement initiatives.
Varda BK, McNabb-Baltar J, Sood A, Ghani KR, Kibel AS, Letendre J, Menon M, Sammon JD, Schmid M, Sun M, et al. Urolithiasis and urinary tract infection among patients with inflammatory bowel disease: a review of US emergency department visits between 2006 and 2009. Urology. 2015;85 (4) :764-70.Abstract
OBJECTIVE: To compare patients with inflammatory bowel disease (IBD) to a general population of urinary stone formers who present to US emergency departments with infected urolithiasis. Patients with IBD are at risk for both infection and stone formation, however studies investigating emergent urolithiasis presentations for this population are limited. METHODS: Using the Nationwide Emergency Department Sample (2006-2009) we identified all patients presenting to the US emergency departments with a diagnosis of upper tract urolithiasis. We then described a subgroup with the concomitant diagnosis of IBD. We compared rates of urinary tract infection (UTI), sepsis, organ failure, admission, and mortality between the 2 groups. Using multivariate analysis, we determined whether or not IBD was a predictor of UTI, sepsis, and hospitalization. RESULTS: Overall, 14,352 patients had concomitant IBD and urolithiasis. IBD patients with urolithiasis presented with infections (10.4% vs 9.1%; P <.001), sepsis (0.6% vs 0.2%; P <.001), and end-organ failure (6.3% vs 1.6%; P <.001) more frequently than non-IBD patients. They were also more likely to have characteristics independently associated with infection and sepsis, such as older age and female gender. In adjusted analyses, IBD was an independent predictor of infection (odds ratio [OR] = 1.3 [1.14-1.46]; P <.0001), sepsis (OR = 1.8 [1.09-2.92]; P <.0001), and admission (OR = 3.3 [3.04-3.64]; P <.0001). CONCLUSION: IBD patients with urinary calculi have greater odds of UTI, renal failure, and sepsis compared to the general stone-forming population. The increased occurrence and severity of infected urolithiasis in this select group of patients warrants screening for stone disease, improved outpatient medical management, and early elective surgery for detected stones.
Schmid M, Gandaglia G, Trinh Q-D. The controversy that will not go away. Eur Urol. 2015;67 (3) :439-40.
Schmid M, Rink M, Traumann M, Bastian PJ, Bartsch G, Ellinger J, Grimm M-O, Hadaschik B, Haferkamp A, Hakenberg OW, et al. Evidence from the 'PROspective MulticEnTer RadIcal Cystectomy Series 2011 (PROMETRICS 2011)' study: how are preoperative patient characteristics associated with urinary diversion type after radical cystectomy for bladder cancer?. Ann Surg Oncol. 2015;22 (3) :1032-42.Abstract
PURPOSE: The aim of this study was to examine preoperative patients' characteristics associated with the urinary diversion (UD) type (continent vs. incontinent) after radical cystectomy (RC) and UD-associated postoperative complications. MATERIALS: In 2011, 679 bladder cancer patients underwent RC at 18 European tertiary care centers. Data were prospectively collected within the 'PROspective MulticEnTer RadIcal Cystectomy Series 2011' (PROMETRICS 2011). Logistic regression models assessed the impact of preoperative characteristics on UD type and evaluated diversion-related complication rates. RESULTS: Of 570 eligible patients, 28.8, 2.6, 59.3, and 9.3% received orthotopic neobladders, continent cutaneous pouches, ileal conduits, and ureterocutaneostomies, respectively. In multivariable analyses, female sex (odds ratio [OR] 3.9; p = 0.002), American Society of Anesthesiologists score ≥3 (OR 2.3; p = 0.02), an age-adjusted Charlson Comorbidity Index ≥3 (OR 4.1; p < 0.001), and a positive biopsy of the prostatic urethra in the last transurethral resection of the bladder prior to RC (OR 4.9; p = 0.03) were independently associated with incontinent UD. There were no significant differences in 30- and/or 90-day complication rates between the UD types. Perioperative transfusion rates and 90-day mortality were significantly associated with incontinent UD (p < 0.001, respectively). Limitations included the small sample size and a certain level of heterogeneity in the application of clinical pathways between the different participating centers. CONCLUSIONS: Within this prospective contemporary cohort of European RC patients treated at tertiary care centers, the majority of patients received an incontinent UD. Female sex and pre-existing comorbidities were associated with receiving an incontinent UD. The risk of overall complications did not vary according to UD type.
Ghatalia P, Je Y, Mouallem NE, Nguyen PL, Trinh Q-D, Sonpavde G, Choueiri TK. Hepatotoxicity with vascular endothelial growth factor receptor tyrosine kinase inhibitors: A meta-analysis of randomized clinical trials. Crit Rev Oncol Hematol. 2015;93 (3) :257-76.Abstract
A meta-analysis of randomized controlled trials (RCT) was conducted to determine the relative risk (RR) of hepatotoxicity with vascular endothelial growth factor receptor (VEGFR) tyrosine kinase inhibitors (TKI). Citations from PubMed/Medline, abstracts from major conferences, and package inserts were reviewed to include RCTs comparing arms with or without a VEGFR TKI. The RRs of all-grade ALT, AST, ALP and bilirubin elevation in 18,282 patients from 52 trials were 1.57 (95% CI 1.38-1.79, p<0.001), 1.57 (95% CI 1.36-1.81, p<0.001), 1.20 (95% CI 1.09-1.83, p<0.001) and 1.55 (95% CI 1.21-1.97, p<0.001) respectively, and high-grade elevations were 1.66 (95% CI 1.25-2.20, p=0.001), 1.61 (95% CI 1.21-2.14, p=0.001), 1.02 (95% CI 0.70-1.47, p=0.932) and 1.34 (95% CI 1.0-1.81, p=0.054) respectively compared to those in the non-TKI group. The incidence of hepatic failure with VEGFR TKIs was 0.8%.
Sood A, Penna FJ, Eleswarapu S, Pucheril D, Weaver J, Abd-El-Barr A-E-R, Wagner JC, Lakshmanan Y, Menon M, Trinh Q-D, et al. Incidence, admission rates, and economic burden of pediatric emergency department visits for urinary tract infection: Data from the nationwide emergency department sample, 2006 to 2011. J Pediatr Urol. 2015.Abstract
BACKGROUND: The Emergency Department (ED) is being increasingly utilized as a pathway for management of acute conditions such as the urinary tract infections (UTIs). OBJECTIVE: We sought to assess the contemporary trends in pediatric UTI associated ED visits, subsequent hospitalization, and corresponding financial expenditure, using a large nationally representative pediatric cohort. Further, we describe the predictors of admission following a UTI associated ED visit. METHODS: The Nationwide Emergency Department Sample (NEDS; 2006-2011) was queried to assess temporal-trends in pediatric (age ≤17 years) ED visits for a primary diagnosis of UTI (ICD9 CM code 590.X, 595.0, and 599.0), subsequent hospital admission, and total charges. These trends were examined using the estimated annual percent change (EAPC) method. Multivariable regression models fitted with generalized estimating equations (GEE) identified the predictors of hospital admission. RESULTS: Of the 1,904,379 children presenting to the ED for management of UTI, 86 042 (4.7%) underwent hospital admission. Female ED visits accounted for almost 90% of visits and increased significantly (EAPC 3.28%; p = 0.003) from 709 visits per 100 000 in 2006 to 844 visits per 100 000 in 2011. Male UTI incidence remained unchanged over the study-period (p = 0.292). The overall UTI associated ED visits also increased significantly during the study-period (EAPC 3.14%; p = 0.006) because of the increase in female UTI associated ED visits. Overall hospital admissions declined significantly over the study-period (EAPC -5.59%; p = 0.021). Total associated charges increased significantly at an annual rate of 18.26%, increasing from 254 million USD in 2006 to 464 million USD in 2011 (p < 0.001; Figure). This increase in expenditure was likely driven by increased utilization of diagnostic CT scanning in these patients (EAPC 22.86%; p < 0.001). Ultrasonography (p = 0.805), X-ray (p = 0.196), and urine analysis/culture use (p = 0.121) did not change over the study-period. In multivariable analysis, the independent predictors of admission included younger age (p < 0.001), male gender (OR = 2.05, p < 0.001), higher comorbidity status (OR = 14.81, p < 0.001), pyelonephritis (OR = 4.45, p < 0.001) and concurrent hydronephrosis (OR = 49.42, p < 0.001), stone disease (OR = 6.44, p < 0.001), or sepsis (OR = 18.83, p < 0.001). DISCUSSION: We show that the incidence of ED visits for pediatric UTI is on the rise. This rise in incidence could be due to several factors, including increasing prevalence of metabolic conditions such as obesity, diabetes and metabolic syndrome in children predisposing them to infections, or could be secondary to increasing sexual activity amongst adolescents and changing patterns of contraceptive use (increased use of OCP in place of condoms), or more simply might just be a reflection of changing practice patterns. Second, we demonstrate that total charges for management of UTI in the ED setting are increasing rapidly; the increase is primarily driven by increasing utilization of diagnostic imaging in the ED setting, as has been demonstrated in other ED based studies as well. CONCLUSIONS: In children presenting to the ED with a primary diagnosis of UTI, total ED charges are increasing at an alarming rate not commensurate with the increase in overall ED visits. While the preponderance of children presenting to the ED for UTI are treated and discharged, 4.7% of patients were admitted to the hospital for further management. The strongest predictors of inpatient admission were pyelonephritis, younger age, male gender, higher comorbidity status, and concurrent hydronephrosis, stone disease, or sepsis. Managing these at-risk patients more aggressively in the outpatient setting may prevent unnecessary ED visits and subsequent hospitalizations, and reduce associated healthcare costs.
Becker A, Pradel L, Kluth L, Schmid M, Eichelberg C, Ahyai S, Trinh Q, Seiler D, Dahlem R, Hansen J, et al. Laparoscopic versus open partial nephrectomy for clinical T1 renal masses: no impact of surgical approach on perioperative complications and long-term postoperative quality of life. World J Urol. 2015;33 (3) :421-6.Abstract
OBJECTIVES: Beyond oncological safety, consideration of 30-day complications according to Clavien-Dindo, as well as postoperative quality of life (QoL) after nephron-sparing surgery for clinical T1 renal masses, represents important factors for treatment decision counseling. The objective of this study was to compare the effect of laparoscopic versus open partial nephrectomy (LPN vs. OPN) on 30-day complications and long-term postoperative QoL for clinical T1 renal masses. METHODS: Retrospective, longitudinal analysis of 293 patients treated with either LPN versus OPN for T1 renal masses. The investigated endpoints were 30-day Clavien-Dindo complications and health-related QoL (EORTC QLQ-C30). Respectively, logistic and linear regression models analyzed the effect of surgical partial nephrectomy approach on endpoints. RESULTS: Overall complication rates were similar in patients undergoing OPN or LPN (16.1 vs. 14.6 %, p = 0.8). Significantly less major complications (2.4 vs. 10.4 %, p = 0.025) occurred after LPN. Despite a shorter convalescence period for LPN patients (p = 0.035), in uni- and multivariable analyses, surgical approach was not associated with 30-day complications nor long-term differences in QoL (all p > 0.05). CONCLUSIONS: Despite a faster recovery time after LPN, our findings suggest that LPN and OPN are equivalent with regard to 30-day Clavien-Dindo complication rates and long-term QoL.
Kim SP, Gross CP, Smaldone MC, Chan L, Van Houten H, Lotan Y, Svatek RS, Thompson RH, Karnes RJ, Trinh Q-D, et al. Perioperative outcomes and hospital reimbursement by type of radical prostatectomy: results from a privately insured patient population. Prostate Cancer Prostatic Dis. 2015;18 (1) :13-7.Abstract
BACKGROUND: With the increasing use of robotic surgery in the United States, the comparative effectiveness and differences in reimbursement of minimally invasive radical prostatectomy (MIRP) and open prostatectomy (ORP) in privately insured patients are unknown. Therefore, we sought to assess the differences in perioperative outcomes and hospital reimbursement in a privately insured patient population who were surgically treated for prostate cancer. METHODS: Using a large private insurance database, we identified 17,610 prostate cancer patients who underwent either MIRP or ORP from 2003 to 2010. The primary outcomes were length of stay (LOS), perioperative complications, 90-day readmissions rates and hospital reimbursement. Multivariable regression analyses were used to evaluate for differences in primary outcomes across surgical approaches. RESULTS: Overall, 8981 (51.0%) and 8629 (49.0%) surgically treated prostate cancer patients underwent MIRP and ORP, respectively. The proportion of patients undergoing MIRP markedly rose from 11.9% in 2003 to 72.5% in 2010 (P<0.001 for trend). Relative to ORP, MIRP was associated with a shorter median LOS (1.0 day vs 3.0 days; P<0.001) and lower adjusted odds ratio of perioperative complications (OR: 0.82; P<0.001). However, the 90-day readmission rates of MIRP and ORP were similar (OR: 0.99; P=0.76). MIRP provided higher adjusted mean hospital reimbursement compared with ORP (US $19,292 vs. US $17,347; P<0.001). CONCLUSIONS: Among privately insured patients diagnosed with prostate cancer, robotic surgery rapidly disseminated with over 70% of patients undergoing MIRP by 2009-2010. Although MIRP was associated with shorter LOS and modestly better perioperative outcomes, hospitals received higher reimbursement for MIRP compared with ORP.
Hu JC, Williams SB, Carter SC, Eggener SE, Prasad S, Chamie K, Trinh Q-D, Sun M, Nguyen PL, Lipsitz SR. Population-based assessment of prostate-specific antigen testing for prostate cancer in the elderly. Urol Oncol. 2015;33 (2) :69.e29-34.Abstract
OBJECTIVES: To perform a population-based analysis to characterize the effect of prostate-specific antigen (PSA) testing on oncologic outcomes in men diagnosed with prostate cancer. MATERIALS AND METHODS: We used the Surveillance, Epidemiology, and End Results-Medicare-linked data to identify 98,883 men diagnosed with prostate cancer from 1996 to 2007. We stratified frequency of PSA testing as none, 1 to 2, 3 to 5, and≥6 tests in the 5 years before prostate cancer diagnosis. We used propensity scoring methods to assess the effect of frequency of PSA testing on likelihood of (1) metastases at diagnosis and (2) overall mortality and prostate cancer-specific mortality. RESULTS: In adjusted analyses, the likelihood of being diagnosed with metastatic prostate cancer decreased with greater frequency of PSA testing (none, 10.6; 1-2, 8.3; 3-5, 3.7; and≥6, 2.5 events per 100 person years, P<0.001). Additionally, greater frequency of PSA testing was associated with improved overall survival and prostate cancer-specific survival (P<0.001 for both). CONCLUSIONS: Greater frequency of PSA testing in men 70 years of age or older in the 5 years before prostate cancer diagnosis is associated with lower likelihood of being diagnosed with metastatic prostate cancer and improved overall and prostate cancer-specific survival.
Sukumar S, Ravi P, Sood A, Gervais M-K, Hu JC, Kim SP, Menon M, Roghmann F, Sammon JD, Sun M, et al. Racial disparities in operative outcomes after major cancer surgery in the United States. World J Surg. 2015;39 (3) :634-43.Abstract
BACKGROUND: Numerous studies have recorded racial disparities in access to care for major cancers. We investigate contemporary national disparities in the quality of perioperative surgical oncological care using a nationally representative sample of American patients and hypothesize that disparities in the quality of surgical oncological care also exists. METHODS: A retrospective, serial, and cross-sectional analysis of a nationally representative cohort of 3,024,927 patients, undergoing major surgical oncological procedures (colectomy, cystectomy, esophagectomy, gastrectomy, hysterectomy, pneumonectomy, pancreatectomy, and prostatectomy), between 1999 and 2009. RESULTS: After controlling for multiple factors (including socioeconomic status), Black patients undergoing major surgical oncological procedures were more likely to experience postoperative complications (OR: 1.24; p < 0.001), in-hospital mortality (OR: 1.24; p < 0.001), homologous blood transfusions (OR: 1.52; p < 0.001), and prolonged hospital stay (OR: 1.53; p < 0.001). Specifically, Black patients have higher rates of vascular (OR: 1.24; p < 0.001), wound (OR: 1.10; p = 0.004), gastrointestinal (OR: 1.38; p < 0.001), and infectious complications (OR: 1.29; p < 0.001). Disparities in operative outcomes were particularly remarkable for Black patients undergoing colectomy, prostatectomy, and hysterectomy. Importantly, substantial attenuation of racial disparities was noted for radical cystectomy, lung resection, and pancreatectomy relative to earlier reports. Finally, Hispanic patients experienced no disparities relative to White patients in terms of in-hospital mortality or overall postoperative complications for any of the eight procedures studied. CONCLUSIONS: Considerable racial disparities in operative outcomes exist in the United States for Black patients undergoing major surgical oncological procedures. These findings should direct future health policy efforts in the allocation of resources for the amelioration of persistent disparities in specific procedures.
Sammon JD, Klett DE, Sood A, Olugbade K, Schmid M, Kim SP, Menon M, Trinh Q-D. Sepsis after major cancer surgery. J Surg Res. 2015;193 (2) :788-94.Abstract
BACKGROUND: Cancer patients undergoing procedures are at increased risk of sepsis. We sought to evaluate the incidence of postoperative sepsis following major cancer surgeries (MCS), and to describe patient and/or hospital characteristics associated with heightened risk. METHODS: Patients undergoing 1 of 8 MCS (colectomy, cystectomy, esophagectomy, gastrectomy, hysterectomy, lung resection, pancreatectomy, and prostatectomy) within the Nationwide Inpatient Sample from 1999-2009 were identified (N = 2,502,710). Logistic regression models fitted with generalized estimating equations were used to estimate primary predictors (procedure, age, gender, race, insurance, Charlson Comorbidity Index, hospital volume, and hospital bed size) effect on sepsis and sepsis-associated mortality. Trends were evaluated with linear regression. RESULTS: The incidence of MCS-related sepsis increased 2.0% per year (P < 0.001), whereas mortality remained stable. Odds of sepsis were highest among esophagectomy patients (odds ratio [OR]: 3.13, 2.76-3.55) and those with non-private insurance (OR: 1.33, 1.19-1.48 to OR: 1.89, 1.71-2.09). Odds of sepsis-related mortality were highest among lung resection patients (OR: 2.30, 2.00-2.64) and those experiencing perioperative liver failure (OR: 5.68, 4.30-7.52). Increasing hospital volume was associated with lower odds of sepsis and sepsis-related mortality (OR: 0.89, 0.84-0.95 to OR: 0.58, 0.53-0.62 and OR: 0.88, 0.77-0.99 to OR: 0.78, 0.67-0.93). CONCLUSIONS: Between 1999 and 2009, the incidence of MCS-related sepsis increased; however, sepsis-related mortality remained stable. Significant disparities exist in patient and hospital characteristics associated with MCS-related sepsis. Hospital volume is an important modifiable risk factor associated with improved sepsis-related outcomes following MCS.
Wang EH, Yu JB, Gross CP, Smaldone MC, Shah ND, Trinh Q-D, Nguyen PL, Sun M, Han LC, Kim SP. Variation in pelvic lymph node dissection among patients undergoing radical prostatectomy by hospital characteristics and surgical approach: results from the National Cancer Database. J Urol. 2015;193 (3) :820-5.Abstract
PURPOSE: Clinical practice guidelines recommend pelvic lymph node dissection at the time of surgery for intermediate or high risk prostate cancer. Therefore, we examined the relationship of pelvic lymph node dissection and detection of lymph node metastasis with hospital characteristics and surgical approach among patients with prostate cancer. MATERIALS AND METHODS: Using the National Cancer Data Base we identified surgically treated patients with pretreatment intermediate or high risk disease from 2010 to 2011. Primary outcomes were treatment with pelvic lymph node dissection and extended pelvic lymph node dissection, as well as the detection of lymph node metastasis. Multivariate logistic regression models were used to test whether hospital characteristics and surgical approach were associated with each outcome. RESULTS: Among the 50,671 surgically treated patients 70.8% (35,876) underwent concomitant pelvic lymph node dissection, 26.6% (9,543) underwent extended pelvic lymph node dissection and 4.5% (1,621) had lymph node metastasis. Pelvic lymph node dissection was performed more often at high volume vs low volume hospitals (81.2% vs 65.4%, adjusted OR 2.20, p=0.01), but less frequently with robotic assisted radical prostatectomy vs open radical prostatectomy (67.5% vs 81.8%, adjusted OR 0.30, p <0.001). Higher odds ratios for lymph node metastasis were also demonstrated with high vs low volume (OR 1.35, p=0.01) and academic vs community hospitals (OR 1.35, p <0.001). However, patients treated with robotic assisted radical prostatectomy had lower odds ratios for lymph node metastasis compared to those undergoing open radical prostatectomy (OR 0.56, p <0.001). CONCLUSIONS: In this cohort a third of patients are not receiving guideline recommended treatment with pelvic lymph node dissection for prostate cancer. Pelvic lymph node dissection and detection of lymph node metastasis varied by surgical approach, hospital volume and academic status.
Sammon JD, McKay RR, Kim SP, Sood A, Sukumar S, Hayn MH, Hu JC, Kibel AS, Nguyen PL, Peabody JO, et al. Burden of hospital admissions and utilization of hospice care in metastatic prostate cancer patients. Urology. 2015;85 (2) :343-9.Abstract
OBJECTIVE: To examine the rates of hospitalization in patients with metastatic prostate cancer (mCaP), as well as the effect of hospice utilization on the cost patterns of mCaP. Over the past decade, dramatic changes in the management of advanced prostate cancer have proceeded alongside changes in end-of-life care. But, the impact of these contemporary advances in management of mCaP and its implications on US health care expenditure remains unknown. METHODS: Patients hospitalized with mCaP from 1998 to 2010 were extracted from the Nationwide Inpatient Sample (n = 100,220). Temporal trends in incidence and charges were assessed by linear regression. Complex samples logistic regression models were used to identify the predictors of in-hospital mortality, elevated hospital charges beyond the 75th percentile and hospice utilization. RESULTS: Between 1998 and 2010, admissions for mCaP decreased at a rate of -5.95% per year (P <.001), whereas per-incident charges increased at the rate of 6.1% (P <.001) annually; the national economic burden of care was stable. Over the study period, hospice use increased 488.0% per year (P <.001) but was significantly lower among black (odds ratio [OR], 0.73; P = .01) and Hispanic (OR, 0.65; P = .03) patients. In multivariable analyses, hospice utilization was associated with decreased odds of elevated hospital charges beyond the 75th percentile (OR, 0.84; P = .02). CONCLUSION: Despite a decline in hospitalizations for mCaP, the economic burden of care has remained stable. Increasing use of hospice services has moderated the effect of rising per-incident hospital charges, highlighting the importance of promoting access to hospice in the right clinical setting. These findings have important policy implications, particularly as advances in treatment are expected to further increase expenditures related to the inpatient management of mCaP.
Roghmann F, Antczak C, McKay RR, Choueiri T, Hu JC, Kibel AS, Kim SP, Kowalczyk KJ, Menon M, Nguyen PL, et al. The burden of skeletal-related events in patients with prostate cancer and bone metastasis. Urol Oncol. 2015;33 (1) :17.e9-18.Abstract
BACKGROUND: To assess contemporary characteristics, hospital admissions, charges, and mortality in patients with prostate cancer (CaP) who have bone metastases and skeletal-related events in an observational study. METHODS: Relying on the Nationwide Inpatient Sample (NIS), patients with CaP with bone metastases between 1998 and 2010 were abstracted. Patients who experienced skeletal-related events were identified, and hospital charges were calculated. Generalized linear regression analyses focused on in-hospital mortality. RESULTS: Between 1998 and 2010, a weighted estimate of 443,929 CaP visits with bone metastases was recorded. Of these, 15.9% experienced at least 1 SRE. The rate of SRE decreased from 18% to 15.4% (1998-2010, estimated annual percent change [EAPC] =-1.44%, P = 0.005) and the SRE-associated mortality decreased from 8.5% to 4.7% (1998-2010, EAPC =-3.68%, P = 0.004). Nevertheless, the inflation-adjusted charges associated with hospital visits of patients with CaP with bone metastases rose by 92% to $1,512,449,106 (EAPC = +8.82%, P<0.001), and SRE charges rose by 94% to $369,256,799 (EAPC =+7.62%, P<0.001). Predictors of in-hospital mortality in patients with SRE included age (odds ratio [OR] = 1.02), comorbidities (≥3 vs. 0-1, OR = 1.72), SRE of the upper limb (OR = 1.75), SRE of the lower limb (OR = 1.35), spinal cord compression (OR = 1.48), radiation (OR = 0.68), surgery (OR = 0.32), and year of hospitalization (2010 vs. 1998, OR = 0.54; all P< 0.03). CONCLUSIONS: From 1998 to 2010, the incidence of SRE and SRE-associated mortality in patients with CaP and bone metastases decreased. However, charges for SRE-associated hospitalizations have increased alarmingly. Future health care policies should strive to provide cost-effective prevention and management of SREs in this population.
Aizer AA, Gu X, Chen M-H, Choueiri TK, Martin NE, Efstathiou JA, Hyatt AS, Graham PL, Trinh Q-D, Hu JC, et al. Cost implications and complications of overtreatment of low-risk prostate cancer in the United States. J Natl Compr Canc Netw. 2015;13 (1) :61-8.Abstract
BACKGROUND: Evidence-based consensus guidelines recommend only observation for men with low-risk prostate cancer and life expectancy less than 10 years. This report describes the incidence, drivers, cost, and morbidity of overtreatment of low-risk prostate cancer within the United States. METHODS: The SEER-Medicare Program was used to identify 11,744 men aged 66 years or older diagnosed with low-risk prostate cancer in 2004 through 2007. Overtreatment of prostate cancer was defined as definitive treatment of a patient with a life expectancy of less than 10 years. Expected survival was estimated using NCCN methodology. Costs were the amount paid by Medicare in years after minus year before diagnosis. Toxicities were relevant Medicare diagnoses/interventions. P values are 2-sided. RESULTS: Of 3001 men with low-risk prostate cancer and a life expectancy of less than 10 years, 2011 men (67%) were overtreated. On multivariable logistic regression, overtreated men were more likely to be married (odds ratio [OR], 1.29; 95% CI, 1.05-1.59; P=.02), reside in affluent regions (P<.001), and harbor more advanced disease at diagnosis (P<.001). Two-year toxicity was greater in overtreated patients (P<.001). Relative to active surveillance/watchful waiting/observation, the median additional cost per definitive treatment was $18,827 over 5 years; the cumulative annual cost attributable to overtreatment in the United States was $58.7 million. The ability to avoid treating the 80% of men with low-grade disease who will never die of prostate cancer would save $1.32 billion per year nationally. CONCLUSIONS: Overtreatment of low-risk prostate cancer is partially driven by sociodemographic factors and occurs frequently, with marked impact on patient quality of life and health-related costs.