Aziz A, May M, Burger M, Palisaar R-J, Trinh Q-D, Fritsche H-M, Rink M, Chun F, Martini T, Bolenz C, et al. Prediction of 90-day mortality after radical cystectomy for bladder cancer in a prospective European multicenter cohort. Eur Urol. 2014;66 (1) :156-63.Abstract
BACKGROUND: Despite recent improvements, radical cystectomy (RC) is still associated with adverse rates for 90-d mortality. OBJECTIVE: To validate the performance of the Isbarn nomogram incorporating age and postoperative tumor characteristics for predicting 90-d RC mortality in a multicenter series and to generate a new nomogram based strictly on preoperative parameters. DESIGN, SETTING, AND PARTICIPANTS: Data of 679 bladder cancer (BCa) patients treated with RC at 18 institutions in 2011 were prospectively collected, from which 597 patients were eligible for final analysis. INTERVENTION: RC for BCa. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: An established prediction tool, the Isbarn nomogram, was applied to our cohort. For the purpose of external validation, model discrimination was measured using the receiver operating characteristics-derived area under the curve. Calibration plots examined the relationship between predicted and observed probabilities. Univariable and multivariable logistic regression models were fitted to assess the impact of preoperative characteristics on 90-d mortality. RESULTS AND LIMITATIONS: The 30-, 60-, and 90-d mortality rates in the development cohort (n=597) were 2.7%, 6.7%, and 9.0%, respectively. The Isbarn nomogram predicted individual 90-d mortality with an accuracy of 68.6%. Our preoperative multivariable model identified age (odds ratio [OR]:1.052), American Society of Anesthesiologists score (OR: 2.274), hospital volume (OR: 0.982), clinically lymphatic metastases (OR: 4.111), and clinically distant metastases (OR: 7.788) (all p<0.05) as independent predictors of 90-d mortality (predictive accuracy: 78.8%). Our conclusions are limited by the lack of an external validation of the preoperative model. CONCLUSIONS: The Isbarn nomogram was validated with moderate discrimination. Our newly developed model consisting of preoperative characteristics might outperform existing models. Our model might be particularly suitable for preoperative patient counseling. PATIENT SUMMARY: The current report validated an established nomogram predicting 90-d mortality in patients with bladder cancer after radical cystectomy (RC). We developed a new prediction tool consisting of strictly preoperative parameters, thus allowing clinicians an optimal consultation for RC candidates.
Aizer AA, Chen M-H, Parekh A, Choueiri TK, Hoffman KE, Kim SP, Martin NE, Hu JC, Trinh Q-D, Nguyen PL. Refusal of curative radiation therapy and surgery among patients with cancer. Int J Radiat Oncol Biol Phys. 2014;89 (4) :756-64.Abstract
PURPOSE: Surgery and radiation therapy represent the only curative options for many patients with solid malignancies. However, despite the recommendations of their physicians, some patients refuse these therapies. This study characterized factors associated with refusal of surgical or radiation therapy as well as the impact of refusal of recommended therapy on patients with localized malignancies. METHODS AND MATERIALS: We used the Surveillance, Epidemiology, and End Results program to identify a population-based sample of 925,127 patients who had diagnoses of 1 of 8 common malignancies for which surgery and/or radiation are believed to confer a survival benefit between 1995 and 2008. Refusal of oncologic therapy, as documented in the SEER database, was the primary outcome measure. Multivariable logistic regression was used to investigate factors associated with refusal. The impact of refusal of therapy on cancer-specific mortality was assessed with Fine and Gray's competing risks regression. RESULTS: In total, 2441 of 692,938 patients (0.4%) refused surgery, and 2113 of 232,189 patients (0.9%) refused radiation, despite the recommendations of their physicians. On multivariable analysis, advancing age, decreasing annual income, nonwhite race, and unmarried status were associated with refusal of surgery, whereas advancing age, decreasing annual income, Asian American race, and unmarried status were associated with refusal of radiation (P<.001 in all cases). Refusal of surgery and radiation were associated with increased estimates of cancer-specific mortality for all malignancies evaluated (hazard ratio [HR], 2.80, 95% confidence interval [CI], 2.59-3.03; P<.001 and HR 1.97 [95% CI, 1.78-2.18]; P<.001, respectively). CONCLUSIONS: Nonwhite, less affluent, and unmarried patients are more likely to refuse curative surgical and/or radiation-based oncologic therapy, raising concern that socioeconomic factors may drive some patients to forego potentially life-saving care.
Gandaglia G, Abdollah F, Hu J, Kim S, Briganti A, Sammon JD, Becker A, Roghmann F, Graefen M, Montorsi F, et al. Is robot-assisted radical prostatectomy safe in men with high-risk prostate cancer? Assessment of perioperative outcomes, positive surgical margins, and use of additional cancer treatments. J Endourol. 2014;28 (7) :784-91.Abstract
INTRODUCTION: Despite a rapid dissemination of robot-assisted radical prostatectomy (RARP) over open radical prostatectomy (ORP), to date no study has compared perioperative outcomes between the two approaches in patients with high-risk prostate cancer (PCa). The aim of our study was to evaluate the safety and feasibility of RARP in this setting. PATIENTS AND METHODS: Overall, 1,512 patients with high-risk PCa within the Surveillance, Epidemiology, and End RESULTS (SEER) Medicare-linked database diagnosed between 2008 and 2009 were abstracted. Patients were treated with RARP or ORP. Postoperative complications, blood transfusions, prolonged length of stay (pLOS), positive surgical margins, and additional cancer therapy rates were compared. Propensity-score matched analyses and logistic regression models fitted with generalized estimating equations for clustering among hospitals were performed. RESULTS: Overall, 706 (46.7%) and 806 (53.3%) patients underwent ORP and RARP, respectively. Following propensity-matched analyses, 706 patients remained. No differences were observed in complications (P=0.6), positive surgical margins (P=0.4), or additional therapy after surgery (P=0.2) between patients treated with RARP and ORP; however, RARP was associated with lower rates of transfusions and shorter hospitalization (all P<0.001). In multivariable analyses, patients undergoing RARP were less likely to receive a blood transfusion (P=0.002) or to experience pLOS (P<0.001) compared with men treated with ORP. CONCLUSIONS: RARP and ORP have comparable complications, positive surgical margins, and additional cancer therapy rates in high-risk PCa. RARP is associated with lower rates of blood transfusions and shorter hospital stays. These findings suggest that RARP is safe and feasible even in this clinical scenario.
Trudeau V, Gandaglia G, Shiffmann J, Popa I, Shariat SF, Montorsi F, Perrotte P, Trinh Q-D, Karakiewicz PI, Sun M. Robot-assisted versus laparoscopic nephroureterectomy for upper-tract urothelial cancer: A population-based assessment of costs and perioperative outcomes. Can Urol Assoc J. 2014;8 (9-10) :E695-701.Abstract
INTRODUCTION: We compared short-term outcomes and costs between robotic-assisted nephroureterectomy (RANU) and laparoscopic radical nephroureterectomy (LNU) in a large population-based cohort of patients with upper-tract urothelial carcinoma (UTUC). METHODS: Overall, 1914 patients with UTUC treated with RANU or LNU between 2008 and 2010 within the Nationwide Inpatient Sample were abstracted. Propensity-score matching was performed to account for inherent differences between patients undergoing RANU and LNU. Multivariable logistic regression models were fitted to compare postoperative complications, blood transfusions, prolonged length of stay, and costs between the 2 procedures. RESULTS: Overall, a weighted estimate of 1199 (62.6%) and 715 (37.4%) patients received LNU and RANU, respectively. In multivariable analyses no significant differences were observed in postoperative transfusion and length of stay between the 2 surgical approaches (all p > 0.1). However, patients undergoing RANU were less likely to experience any complications compared to their counterparts undergoing LNU (p = 0.04). The utilization of RANU was associated with substantially higher costs compared to the laparoscopic approach. Our study is limited by its retrospective nature and the lack of adjustment for tumour stage and grade. CONCLUSIONS: Our results support the safety and feasibility of RANU for the treatment of UTUC. Indeed, the use of the robotic approach was associated with lower probability of experiencing perioperative complications compared to LNU. On the other hand, the utilization of RANU is associated with higher costs compared to LNU.
Schmid M, Trinh Q-D, Graefen M, Fisch M, Chun FK, Hansen J. The role of biomarkers in the assessment of prostate cancer risk prior to prostate biopsy: which markers matter and how should they be used?. World J Urol. 2014;32 (4) :871-80.Abstract
Prostate cancer (PCa) screening has been substantially influenced by the clinical implementation of serum prostate-specific antigen (PSA). In this context, improvement of early PCa detection and stage migration as well as reduced PCa mortality were achieved, and up-to-date PSA represents the gold standard biomarker of PCa diagnosis together with clinical findings. Nonetheless, PSA shows weakness in discriminating between malign and benign prostatic disease or indolent and aggressive cancers. As a result, the expansion of PSA screening is extensively debated with regard to overdetection and ultimately overtreatment, keeping in mind that PCa is still the third leading cause of cancer-specific mortality in the Western male population. Consequently, today's task is to increase the accuracy of PCa detection and furthermore to allow stratification for indolent PCa that might permit active surveillance and to filter out aggressive cancers necessitating treatment. Thus, novel biomarkers, especially in combination with approved clinical risk factors (e.g., age or family history of PCa), within multivariable prediction models carry the potential to improve many aspects of PCa diagnosis and to enable risk classification in clinical practice. Multivariable models lead to superior accuracy for PCa prediction instead of the use of a single risk factor. The aim of this article was to present an overview of known risk factors for PCa together with new promising blood- and urine-based biomarkers and their application within risk models that may allow risk stratification for PCa prior to prostate biopsy. Risk models may optimize PCa detection and classification with regard to improved PCa risk assessment and avoidance of unnecessary prostate biopsies.
Mahal BA, Aizer AA, Ziehr DR, Hyatt AS, Sammon JD, Schmid M, Choueiri TK, Hu JC, Sweeney CJ, Beard CJ, et al. Trends in disparate treatment of African American men with localized prostate cancer across National Comprehensive Cancer Network risk groups. Urology. 2014;84 (2) :386-92.Abstract
OBJECTIVE: To determine whether African Americans (AAs) with intermediate- to high-risk prostate cancer (PCa) receive similar treatment as white patients and whether any observed disparities are narrowing with time. METHODS: We used Surveillance, Epidemiology, and End Results to identify 128,189 men with localized intermediate- to high-risk PCa (prostate-specific antigen ≥10 ng/mL, Gleason score ≥7, or T stage ≥T2b) diagnosed from 2004 to 2010. We used multivariate logistic regression analyses to determine the impact of race on the receipt of definitive treatment. RESULTS: AA men were significantly less likely to receive curative-intent treatment than white men (adjusted odds ratio [AOR], 0.82; 95% confidence interval [CI], 0.79-0.86; P <.001). There was no evidence of this disparity narrowing over time (Pinteraction 2010 vs 2004 = .490). Disparities in the receipt of treatment between AA and white men were significantly larger in high-risk (AOR, 0.60; 95% CI, 0.56-0.64; P <.001) than in intermediate-risk disease (AOR, 0.92; 95% CI, 0.88-0.97; P = .04; Pinteraction <.001). After adjusting for treatment, demographics, and prognostic factors, AA men had a higher risk of prostate cancer-specific mortality (adjusted hazard ratio, 1.12; 95% CI, 1.01-1.25; P = .03). CONCLUSION: AA men with intermediate- to high-risk PCa are less likely to be treated with curative intent than white men. This disparity is worse in high-risk disease and is not improving over time. Factors underlying this treatment disparity should be urgently studied as it is a potentially correctable contributor to excess PCa mortality among AA patients.
Sammon JD, Trinh Q-D, Menon M. Use of advanced treatment technologies among men at low risk of dying from prostate cancer. BJU Int. 2014;114 (2) :166-7.
Bienz M, Hueber P-A, Al-Hathal N, McCormack M, Bhojani N, Trinh Q-D, Zorn KC. Accuracy of transrectal ultrasonography to evaluate pathologic prostate weight: correlation with various prostate size groups. Urology. 2014;84 (1) :169-74.Abstract
OBJECTIVE: To report the accuracy of transrectal ultrasonography (TRUS) to measure prostate size before robotic-assisted radical prostatectomy using the prolate ellipsoid formula and its correlation to the weight of the postoperative prostate specimen, for different prostate size groups. METHODS: Preoperative prostate size estimated by TRUS and the weight of postoperative prostate specimens were collected from 440 men undergoing robotic-assisted radical prostatectomy. Patients were grouped according to preoperative prostate size: <30, 30-60, 60-80, and ≥80 g. To evaluate accuracy, the mean absolute percentage of error was used. The mean percentage of error was used to indicate whether the estimation of TRUS had a tendency to overestimate or underestimate prostate size. The correlation between both measurements was analyzed for each size group. RESULTS: Accuracy of TRUS estimation was associated with increased prostate size. TRUS estimation was more accurate for larger prostates. The mean absolute percentage of error of each group was 38.64% (<30 g), 21.33% (30-60 g), 13.23% (60-80 g), and 14.96% (≥80 g). Correlation followed a similar size-dependent trend, with a stronger r coefficient for larger prostates: 0.174 (<30 g), 0.327 (30-60 g), 0.457 (60-80 g), and 0.839 (≥80 g). Interestingly, smaller prostates were underestimated, whereas larger glands (≥80 g) had a tendency to be overestimated by TRUS. CONCLUSION: This study demonstrates that the accuracy of the prolate ellipsoid formula for TRUS varies according to prostate size. Although this formula is fairly accurate for assessing larger prostates, it shows some limitations for smaller prostates. This must be taken into account when evaluating treatment modalities such as transurethral incision of the prostate and brachytherapy.
Aizer AA, Falit B, Mendu ML, Chen M-H, Choueiri TK, Hoffman KE, Hu JC, Martin NE, Trinh Q-D, Alexander BM, et al. Cancer-specific outcomes among young adults without health insurance. J Clin Oncol. 2014;32 (19) :2025-30.Abstract
PURPOSE: The Patient Protection and Affordable Care Act (ACA) will likely improve insurance coverage for most young adults, but subsets of young adults in the United States will face significant premium increases in the individual market. We examined the association between insurance status and cancer-specific outcomes among young adults. METHODS: We used the SEER program to identify 39,447 patients age 20 to 40 years diagnosed with a malignant neoplasm between 2007 and 2009. The association between insurance status and stage at presentation, employment of definitive therapy, and all-cause mortality was assessed using multivariable logistic or Cox regression, as appropriate. RESULTS: Patients who were uninsured were more likely to be younger, male, nonwhite, and unmarried than patients who were insured and were also more likely to be from regions of lower income, education, and population density (P < .001 in all cases). After adjustment for pertinent confounding variables, an association between insurance coverage and decreased likelihood of presentation with metastatic disease (odds ratio [OR], 0.84; 95% CI, 0.75 to 0.94; P = .003), increased receipt of definitive treatment (OR, 1.95; 95% CI, 1.52 to 2.50; P < .001), and decreased death resulting from any cause (hazard ratio, 0.77; 95% CI, 0.65 to 0.91; P = .002) was noted. CONCLUSION: The improved coverage fostered by the ACA may translate into better outcomes among most young adults with cancer. Extra consideration will need to be given to ensure that patients who will face premium increases in the individual market can obtain insurance coverage under the ACA.
Gandaglia G, Ravi P, Abdollah F, Abd-El-Barr A-E-RM, Becker A, Popa I, Briganti A, Karakiewicz PI, Trinh Q-D, Jewett MA, et al. Contemporary incidence and mortality rates of kidney cancer in the United States. Can Urol Assoc J. 2014;8 (7-8) :247-52.Abstract
INTRODUCTION: This is a timely update of incidence and mortality for renal cell carcinoma (RCC) in the United States. METHODS: Relying on the Surveillance, Epidemiology, and End Results (SEER) database, we computed age-adjusted incidence, mortality rates and 5-year cancer-specific survival (CSS) for patients with histologically confirmed kidney cancer between 1975 and 2009. Long-term (1975-2009) and short-term (2000-2009) trends were examined by joinpoint analysis, and quantified using the annual percent change (APC). The reported findings were stratified according to disease stage. RESULTS: Age-adjusted incidence rates of RCC increased by +2.76%/year between 1975 and 2009 (from 6.5 to 17.1/100 000 person-years, p < 0.001), and by +2.85%/year between 2000 and 2009 (p < 0.001). For the same time points, the corresponding APC for the incidence of localized stage were +4.55%/year (from 3.0 to 12.2/100 000 person years, p < 0.001), and +4.42%/year (p < 0.001), respectively. The incidence rates of regional stage increased by +0.88%/year between 1975 and 2009 (p < 0.001), but stabilized in recent years (2000-2009: +0.56%/year, p = 0.4). Incidence rates of distant stage remained unchanged in long- and short-term trends. Overall mortality rates increased by +1.72%/year between 1975 and 2009 (from 1.2 to 5.0/100 000 person-years, P<0.001), but stabilized between 1994 and 2004 (p = 0.1). Short-term mortality rates increased in a significant fashion by +3.14%/year only for localized stage (p < 0.001). INTERPRETATION: In contemporary years, there is a persisting upward trend in incidence and mortality of localized RCC.
Murphy DG, Loeb S, Basto MY, Challacombe B, Trinh Q-D, Leveridge M, Morgan T, Dasgupta P, Bultitude M. Engaging responsibly with social media: the BJUI guidelines. BJU Int. 2014;114 (1) :9-11.
Antczak C, Trinh VQ, Sood A, Ravi P, Roghmann F, Trudeau V, Chang SL, Karakiewicz PI, Kibel AS, Krishna N, et al. The health care burden of skeletal related events in patients with renal cell carcinoma and bone metastasis. J Urol. 2014;191 (6) :1678-84.Abstract
PURPOSE: We examined temporal trends in skeletal related events and associated charges in patients with renal cell carcinoma metastatic to bone. We also identified patient and hospital characteristics associated with skeletal related events and related mortality. MATERIALS AND METHODS: Using the Nationwide Inpatient Sample we abstracted data on patients with renal cell carcinoma who were diagnosed with concomitant bone metastasis between 1998 and 2010. Patients who experienced a skeletal related event were identified and hospital charges were calculated. Multivariate regression models fitted with generalized estimating equations were used to examine predictors of skeletal related events and related in-hospital mortality. RESULTS: Between 1998 and 2010 a weighted estimate of 144,889 renal cell carcinoma hospital visits of patients with bone metastasis was identified in the Nationwide Inpatient Sample, of which 20.8% involved a skeletal related event. In these cases from 1998 to 2010 the inflation adjusted mean yearly costs associated with hospital admission increased by 207% in 2013 United States dollars (estimated annual percent change 8.94%, p<0.001). Conversely, the rates of skeletal related events and skeletal related event associated mortality decreased significantly (estimated annual percent change -1.11% and -2.9%, respectively, each p<0.001). CONCLUSIONS: The prevalence and in-hospital mortality of skeletal related event associated hospitalization for metastatic renal cell carcinoma is decreasing but such charges to health care in the United States are increasing at an alarming rate. These findings highlight the need for cost-effective treatment strategies to prevent or treat these morbid complications.
Gandaglia G, Karakiewicz PI, Trinh Q-D, Sun M. High hospital volume reduces mortality after cystectomy. BJU Int. 2014;114 (1) :5-6.
Sukumar S, Djahangirian O, Sood A, Sammon JD, Varda B, Janosek-Albright K, Abd-El-Barr A-E-R, Sun M, Trinh Q-D. Minimally invasive vs open pyeloplasty in children: the differential effect of procedure volume on operative outcomes. Urology. 2014;84 (1) :180-4.Abstract
OBJECTIVE: To assess the differential effect of volume-outcome dynamics on the outcomes of open pyeloplasty (OP) and minimally invasive pyeloplasty (MIP) in the management of pediatric ureteropelvic junction obstruction in the setting of increasing utilization of MIP. METHODS: Within the Nationwide Inpatient Sample, a weighted estimate of 6006 pediatric patients (≤18 years; 2008-2010) with ureteropelvic junction obstruction underwent either OP or MIP. National trends in utilization and comparative effectiveness outcomes were examined in terms of intraoperative and postoperative complications, prolonged length of stay, and excessive hospital charges. Hospitals were stratified into volume quartiles. Specifically, the volume-outcome dynamics of the highest and lowest volume quartiles of both the approaches were examined with binary logistic regression models. RESULTS: MIP accounted for 17.2% of cases during the study years. In individual multivariate models, high-volume OP patients had a significantly lower risk of developing postoperative complications, genitourinary complications, and excessive hospital charges compared with high-volume MIP, low-volume OP, and low-volume MIP patients. Regardless of hospital volume, MIP patients experienced shorter hospital stays. CONCLUSION: Although there has been a substantial increase in the utilization of MIP, high-volume hospitals performing OP have the best perioperative outcomes in terms of postoperative complications, genitourinary complications, and overall hospital charges. However, high-volume hospitals performing MIP have better outcomes compared with low-volume hospitals performing OP. Shorter hospital stay is the one mitigating factor of MIP.
Kim SP, Gross CP, Nguyen PL, Smaldone MC, Shah ND, Karnes JR, Thompson HR, Han LC, Yu JB, Trinh QD, et al. Perceptions of Active Surveillance and Treatment Recommendations for Low-risk Prostate Cancer: Results from a National Survey of Radiation Oncologists and Urologists. Med Care. 2014;52 (7) :579-85.Abstract
BACKGROUND: With the growing concerns about overtreatment in prostate cancer, the extent to which radiation oncologists and urologists perceive active surveillance (AS) as effective and recommend it to patients are unknown. OBJECTIVE: To assess opinions of radiation oncologists and urologists about their perceptions of AS and treatment recommendations for low-risk prostate cancer. RESEARCH DESIGN: National survey of specialists. PARTICIPANTS: Radiation oncologists and urologists practicing in the United States. MEASURES: A total of 1366 respondents were asked whether AS was effective and whether it was underused nationally, whether their patients were interested in AS, and treatment recommendations for low-risk prostate cancer. Pearson's χ test and multivariate logistic regression were used to test for differences in physician perceptions on AS and treatment recommendations. RESULTS: Overall, 717 (52.5%) of physicians completed the survey with minimal differences between specialties (P=0.92). Although most physicians reported that AS is effective (71.9%) and underused in the United States (80.0%), 71.0% stated that their patients were not interested in AS. For low-risk prostate cancer, more physicians recommended radical prostatectomy (44.9%) or brachytherapy (35.4%); fewer endorsed AS (22.1%). On multivariable analysis, urologists were more likely to recommend surgery [odds ratio (OR): 4.19; P<0.001] and AS (OR: 2.55; P<0.001), but less likely to recommend brachytherapy (OR: 0.13; P<0.001) and external beam radiation therapy (OR: 0.11; P<0.001) compared with radiation oncologists. CONCLUSIONS AND RELEVANCE: Most prostate cancer specialists in the United States believe AS effective and underused for low-risk prostate cancer, yet continue to recommend the primary treatments their specialties deliver.
McNabb-Baltar J, Ravi P, Isabwe GA, Suleiman SL, Yaghoobi M, Trinh Q-D, Banks PA. A population-based assessment of the burden of acute pancreatitis in the United States. Pancreas. 2014;43 (5) :687-91.Abstract
OBJECTIVES: The aim of this study is to investigate the incidence and mortality of emergency department (ED) visits in the United States attributed to acute pancreatitis (AP) and quantify predictors of admission and mortality. METHODS: Using the nationwide ED sample, all ED visits between 2006 and 2009 for AP were extracted. Multivariable analyses were fitted for prediction of admission and mortality. RESULTS: A weighted sample of 1,224,121 patient visits with AP was captured. Of those, 75.4% resulted in admission and 0.7% died. Between 2006 and 2009, the incidence of AP ED visits increased from 9.9 to 10.6 per 10,000 person-years. Patients were more likely to be admitted if sicker (Charlson Comorbidity Index score ≥ 3; OR, 6.48; P < 0.001) and if the etiology of pancreatitis was alcoholic versus biliary (OR, 2.20; P < 0.001). They were more likely to die if sicker (Charlson Comorbidity Index score ≥ 3; OR, 1.51; P < 0.001) and covered with Medicare or Medicaid versus private insurance (OR, 1.40; P < 0.001 and OR, 1.45; P < 0.001, respectively). CONCLUSIONS: Emergency department visits for AP represent a significant burden on US health care. Although mortality is lower than previously reported, significant disparities exist in patients presenting with AP with regard to admission and mortality rates. Further investigations are needed to assess these disparities.
Sammon JD, Sharma P, Rahbar H, Roghmann F, Ghani KR, Sukumar S, Karakiewicz PI, Peabody JO, Elder JS, Menon M, et al. Predictors of admission in patients presenting to the emergency department with urinary tract infection. World J Urol. 2014;32 (3) :813-9.Abstract
PURPOSE: Previous studies examining the management of urinary tract infections (UTI) showed marked variability in the economical burden of care, with a tenfold increase in costs when patients require admission to the hospital. We sought to examine the patient and emergency department (ED) characteristics associated with hospitalization in patients presenting to the ED with UTI. METHODS: An estimate of 10,798,343 patients with a primary diagnosis of UTI was presented to the ED from 2006 to 2009 and was abstracted from the Nationwide Emergency Department Sample. Univariable and multivariable analyses examined patient and hospital characteristics of those admitted with UTI. RESULTS: Between 2006 and 2009, 10.8 million patients presented to the ED in the United States for the treatment of UTI and 1.8 million patients (16.7 %) were admitted to the hospital for further management. Admitted patients were older, and a higher proportion had pyelonephritis, was male, and had Medicare. Admitted patients were also more likely to be seen at urban teaching hospitals, and/or treated at zip codes with higher median incomes. Following multivariable analysis, the independent predictors of admission included pyelonephritis (OR 5.29, 95 % CI 5.23-5.35), male gender (OR 1.58, 95 % CI 1.56-1.59), and advancing age (OR 1.037, 95 % CI 1.037-1.037). CONCLUSIONS: Expansion in ED utilization for the management of UTI has exceeded previous estimates. While the preponderance of patients presenting to the ED for UTI is discharged home, 16.7 % are admitted for further management. Predictors of inpatient admission on multivariable analyses included pyelonephritis, advancing age, and male gender.
Ravi P, Bianchi M, Hansen J, Trinh Q-D, Tian Z, Meskawi M, Abdollah F, Briganti A, Shariat SF, Perrotte P, et al. Benefit in regionalisation of care for patients treated with radical cystectomy: a nationwide inpatient sample analysis. BJU Int. 2014;113 (5) :733-40.Abstract
OBJECTIVE: To quantify in absolute terms the potential benefit of regionalisation of care from low- to high-volume hospitals. PATIENTS AND METHODS: Patients with a primary diagnosis of bladder cancer treated with radical cystectomy (RC) were identified within the Nationwide Inpatient Sample, a retrospective observational population-based cohort of the USA, between 1998 and 2009. Intraoperative and postoperative complications, blood transfusions, prolonged length of stay, and in-hospital mortality rates represented the outcomes of interest. Potentially avoidable outcomes were calculated by subtracting predicted rates (i.e. estimated outcomes if care was delivered at a high-volume hospital) from observed rates (i.e. actual observed outcomes after care delivered at a low-volume hospital). Multivariable logistic regression models and number needed to treat were generated. RESULTS: Patients treated at high-volume hospitals had lower odds of complications during hospitalisation than those treated in low-volume hospitals. Potentially avoidable intraoperative complications, postoperative complications, blood transfusions, prolonged hospitalisation, and in-hospital mortality rates were 0.6, 7.4, 2.8, 9.4, and 2.0%, respectively. This corresponds to a number needed to redirect from low- to high-volume hospitals in order to avoid one adverse event of 166, 14, 36, 11 and 50, respectively. CONCLUSION: This is the first report to quantify the potential benefit of regionalisation of RC for muscle-invasive bladder cancer to high-volume hospitals.
Wang LC, Xylinas E, Kent MT, Kluth LA, Rink M, Jamzadeh A, Rieken M, Al Hussein Al Awamlh B, Trinh Q-D, Sun M, et al. Combining smoking information and molecular markers improves prognostication in patients with urothelial carcinoma of the bladder. Urol Oncol. 2014;32 (4) :433-40.Abstract
OBJECTIVES: Tissue-based markers improve the accuracy of prediction models in urothelial carcinoma of the bladder (UCB). Current smoking status and cumulative exposure also affect outcomes. To evaluate whether the combination of molecular markers and smoking features further improved the prognostication of patients who underwent radical cystectomy (RC) for UCB. MATERIALS AND METHODS: A total of 588 patients underwent RC and bilateral lymphadenectomy for UCB from 1995 to 2005. Immunohistochemistry for p53, p21, pRB, p27, Ki-67, and survivin was performed on tissue microarrays from the RC specimen. Smoking features were routinely assessed at diagnosis. Multivariable Cox regression models assessed time to disease recurrence and cancer-specific mortality. RESULTS: Of the 588 patients, 128 were never (22%), 283 former (48%), and 177 current smokers (30%). In total, 227 patients experienced disease recurrence, whereas 190 died of UCB. Smoking status was independently associated with both outcomes (hazard ratio [HR] = 1.48 and 2.62, for former and current vs. never smokers, respectively, P<0.001). All markers were significantly associated with both outcomes (P<0.05) except for survivin. The combination of the 4 cell cycle markers p53, p21, pRB, and p27 increased the discrimination of clinicopathologic model for former and current vs. never smokers with c-indices 0.779 and 0.780, respectively (base model c-indices of 0.741 and 0.740 for former and current vs. never smokers, respectively). The further addition of smoking features and biomarker status improved the discrimination of the model (c-indices of 0.783 and 0.786 for former and current vs. never smokers, respectively). CONCLUSIONS: We confirmed that smoking information and tissue markers status improve prognostication of UCB outcomes after RC; the combination of both reaching the highest level of discrimination.
Gandaglia G, Sammon JD, Chang SL, Choueiri TK, Hu JC, Karakiewicz PI, Kibel AS, Kim SP, Konijeti R, Montorsi F, et al. Comparative effectiveness of robot-assisted and open radical prostatectomy in the postdissemination era. J Clin Oncol. 2014;32 (14) :1419-26.Abstract
PURPOSE: Given the lack of randomized trials comparing robot-assisted radical prostatectomy (RARP) and open radical prostatectomy (ORP), we sought to re-examine the outcomes of these techniques using a cohort of patients treated in the postdissemination era. PATIENTS AND METHODS: Overall, data from 5,915 patients with prostate cancer treated with RARP or ORP within the SEER-Medicare linked database diagnosed between October 2008 and December 2009 were abstracted. Postoperative complications, blood transfusions, prolonged length of stay (pLOS), readmission, additional cancer therapies, and costs of care within the first year after surgery were compared between the two surgical approaches. To decrease the effect of unmeasured confounders, instrumental variable analysis was performed. Multivariable logistic regression analyses were then performed. RESULTS: Overall, 2,439 patients (41.2%) and 3,476 patients (58.8%) underwent ORP and RARP, respectively. In multivariable analyses, patients undergoing RARP had similar odds of overall complications, readmission, and additional cancer therapies compared with patients undergoing ORP. However, RARP was associated with a higher probability of experiencing 30- and 90-day genitourinary and miscellaneous medical complications (all P ≤ .02). Additionally, RARP led to a lower risk of experiencing blood transfusion and of having a pLOS (all P < .001). Finally, first-year reimbursements were greater for patients undergoing RARP compared with ORP (P < .001). CONCLUSION: RARP and ORP have comparable rates of complications and additional cancer therapies, even in the postdissemination era. Although RARP was associated with lower risk of blood transfusions and a slightly shorter length of stay, these benefits do not translate to a decrease in expenditures.