INTRODUCTION:Our goal was to determine if board certification status was associated with improved postoperative outcomes for certain urologic oncology operations. METHODS:We performed a retrospective cohort study of patients aged 65 and over having radical prostatectomy (RP), radical cystectomy (RC), and radical or partial nephrectomy (RPN) by surgeons with New York State licenses from 2015 to 2021 using the Medicare limited dataset. Our primary exposure was surgeon American Board of Urology certification determined by the New York State Physician Profile. All surgeons were in practice for at least 5 years. Our primary outcomes were 90-day mortality, 30-day unplanned readmission, and hospital length of stay (LOS). We used multivariable linear and logistic regression adjusted for surgeon, hospital, and patient characteristics. We performed the analysis in R, and 2-sided P values < .05 were considered statistically significant. RESULTS:We identified 12,601 patients who had a procedure performed. At the time of the procedure, a minority of procedures (1.3%) were performed by nonboard-certified (NBC) urologists. Among the patient cohort, there were 262 and 1419 mortality and readmission events, respectively; median LOS was 2 days (interquartile range 1155). Patients operated on by NBC urologists tended to have lower-volume surgeons who were less likely to be fellowship trained and to have surgery at smaller hospitals. Patients treated by NBC urologists were more likely to have RP, and less likely to have RC and RPN. On multivariate analysis, board certification was protective against readmission for RP (P < .001) and RC (P = .02), longer LOS for RC (P = .001), and mortality for RPN (P = .008). CONCLUSIONS:Urology board certification was associated with fewer readmissions after RP and RC, a shorter LOS after RC, and a lower risk of mortality after RPN. Given low event numbers, these findings require validation with a larger dataset.

The cost of postpartum hemorrhage (PPH) has not been well described. Our objective is to explicity describe the cost of care related to the severity of and intervenions required to treat a postpartum hemorrhage. These data can be used to assess care interventions (medications, devices, surgical procedures) designed to reduce adverse outcomes by estimating cost avoidance in comparison to the cost attributed to the intervention itself. Value in healthcare is defined as the health outcomes achieved per dollar spent (Value=Quality/Cost).

tomography for residual fragments 2mm. The secondary outcome was the influence of stone volume and density in the two modalities and complication rates between the two groups. RESULTS: A total of 93 patients completed the protocol, 45 in group 1 and 48 in group 2. Patients in group 2 were older (48 vs. 42, p [ 0,027) and all other demographic characteristics were comparable. Number of pre-stented patients and stone diameter, density, volume and location (inferior pole and non-inferior pole) were similar in both groups. The mean stone diameter and volume were 13,4 4,7 mm and 484 403 mm, respectively. The SFR was not significantly different between groups (66,7 vs. 68,8% p [ 0,751) and multivariate analysis revealed that higher BMI was associated with better SFR (1,17 OR 95% IC 1,02 e 1,34, p [ 0,022). Stone volume (p [ 0,179) and density (p [ 0,884) did not influence the SFR on univariate analysis between the two modalities of fragmentation. There were no statistically significant differences in operative time, complication rates or ancillary procedures between groups. CONCLUSIONS: The stone free rate was comparable for active fragments basketing or stone dusting and spontaneous fragment passage during flexible ureteroscopy with holmiun laser lithotripsy on 90 days follow up. There was no influence of stone volume and density in both modalities. Post-operative complication rates and need of ancillary procedures were similar between groups. Both fragmentation techniques are efficacious and could be performed according to surgeon's preference.

You have accessJournal of UrologySurgical Technology & Simulation: Instrumentation & Technology II (PD41)1 Sep 2021PD41-09 VARIABILITY IN COST-EFFECTIVE PRICE POINTS FOR SINGLE-USE CYSTOSCOPES BASED ON PRACTICE VOLUME: A REAL-WORLD ANALYSIS OF TWO PRACTICES IN A MAJOR URBAN CENTER Evan Garden, James Young, Osama Al-Alao, Darren Deoraj, Greg Hruby, Alexander Small, and Michael Palese Evan GardenEvan Garden More articles by this author , James YoungJames Young More articles by this author , Osama Al-AlaoOsama Al-Alao More articles by this author , Darren DeorajDarren Deoraj More articles by this author , Greg HrubyGreg Hruby More articles by this author , Alexander SmallAlexander Small More articles by this author , and Michael PaleseMichael Palese More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002051.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The traditional cost of reusable cystoscopes (RC) is derived from up-front purchasing, repair fees and equipment reprocessing, whereas single-use, disposable cystoscopes (DC) trade off these indirect expenses for higher direct costs. Therefore, the point at which DCs become more cost-effective than RCs depends primarily on the price of the DC itself. We sought to define the optimal price point for cost-effectiveness of the Ambu® DC (aScope™ 4) versus the Olympus® digital RC (CYF-VHR and V2) for cystoscopies performed in two outpatient clinical settings: a high-volume (HV) multi-provider practice and low-volume (LV) single-provider practice. METHODS: The number of cystoscopies performed at HV and LV between 1/2019-12/2019 was recorded. A micro-costing analysis was performed for DC and RC procedures, incorporating purchasing price, sterilization supplies, repair fees, and personnel costs. Using a variable pricing model, the optimal DC price was calculated – that is, the price of each individual DC, valve seal, and stopcock at which the per-case cost for cystoscopy performed with DC and RC was equal. RESULTS: Cystoscopies performed at the HV [n=1984] and LV[n=245] utilized nine and two RCs, respectively. Taking into consideration relevant expenses for procedures at each clinic, the HV operated at a cost of $65.98/case and the LV operated at a cost of $232.62/case with reusable equipment. For a complete transition from reusable-to-disposable equipment to be economically feasible, the HV would need to purchase each DC at a maximum price of $46.60 to maintain cost-effectiveness. At the LV practice the maximum cost-effective price for DCs would be $28.64. CONCLUSIONS: For both practices, an economically feasible DC price was <$50. This price was lower for the LV practice, suggesting that a practice run entirely with disposable equipment may be less financially feasible for low- versus high-volume clinics. Purchasing groups must be familiar with the economic implications of varying price points during negotiations to mitigate financial strain on the practice. Source of Funding: N/A © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e684-e684 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Evan Garden More articles by this author James Young More articles by this author Osama Al-Alao More articles by this author Darren Deoraj More articles by this author Greg Hruby More articles by this author Alexander Small More articles by this author Michael Palese More articles by this author Expand All Advertisement Loading ...

Introduction: Disposable single-use cystoscopes have become increasingly available, demonstrating comparable quality to reusable cystoscopes while eliminating the need for reprocessing and repairs. However, high costs remain a concern. To clarify the role for these scopes, we performed a cost analysis comparison between the single-use Ambu (R) aScope (TM) 4 cystoscope and reusable Olympus (R) CYF-VHR and V2 cystoscopes in 2 clinical settings: a high- volume multi-provider practice and low-volume single-provider practice. Methods: The number of cystoscopies at each center was recorded between January and December 2019. Elements in the micro-costing analysis included the original purchasing price of the cystoscopes plus accessory equipment, sterilization supplies, repair costs, and personnel. Costs were amortized over 5 or 10 years and calculated on a per-case basis. An annual total cost analysis was performed to evaluate the cost-effectiveness of each device for each facility. Results: In 2019, 1,984 and 245 cystoscopic procedures were performed at the high and low-volume clinics, respectively. At the high-volume multi-provider practice, per-case cost for reusable cystoscopy amounted to $65.98 compared to $227.18 for single-use cystoscopy, with reusable equipment more cost-effective after 294 cystoscopies. At the low-volume single-provider practice, the per-case cost for reusable cystoscopy was $232.62 compared to $461.18 for single-use cystoscopy, with reusable equipment more cost-effective after 19 cases. Conclusions: Based on this micro-costing analysis, per-case costs favor reusable cystoscopes. While single-use cystoscope pricing may be prohibitive for large and small facilities at this present time, these instruments are powerful adjuncts to urologists' armamentaria when portability and efficiency are prioritized.

Cohort identification for clinical studies tends to be laborious, time-consuming, and expensive. Developing automated or semi-automated methods for cohort identification is one of the "holy grails" in the field of biomedical informatics. We propose a high-throughput similarity-based cohort identification algorithm by applying numerical abstractions on electronic health records (EHR) data. We implement this algorithm using the Observational Medical Outcomes Partnership (OMOP) Common Data Model (CDM), which enables sites using this standardized EHR data representation to avail this algorithm with minimum effort for local implementation. We validate its performance for a retrospective cohort identification task on six clinical trials conducted at the Columbia University Medical Center. Our algorithm achieves an average area under the curve (AUC) of 0.966 and an average Precision at 5 of 0.983. This interoperable method promises to achieve efficient cohort identification in EHR databases. We discuss suitable applications of our method and its limitations and propose warranted future work.

OBJECTIVE:To develop an open-source information extraction system called Eligibility Criteria Information Extraction (EliIE) for parsing and formalizing free-text clinical research eligibility criteria (EC) following Observational Medical Outcomes Partnership Common Data Model (OMOP CDM) version 5.0. MATERIALS AND METHODS:EliIE parses EC in 4 steps: (1) clinical entity and attribute recognition, (2) negation detection, (3) relation extraction, and (4) concept normalization and output structuring. Informaticians and domain experts were recruited to design an annotation guideline and generate a training corpus of annotated EC for 230 Alzheimer's clinical trials, which were represented as queries against the OMOP CDM and included 8008 entities, 3550 attributes, and 3529 relations. A sequence labeling-based method was developed for automatic entity and attribute recognition. Negation detection was supported by NegEx and a set of predefined rules. Relation extraction was achieved by a support vector machine classifier. We further performed terminology-based concept normalization and output structuring. RESULTS:In task-specific evaluations, the best F1 score for entity recognition was 0.79, and for relation extraction was 0.89. The accuracy of negation detection was 0.94. The overall accuracy for query formalization was 0.71 in an end-to-end evaluation. CONCLUSIONS:This study presents EliIE, an OMOP CDM-based information extraction system for automatic structuring and formalization of free-text EC. According to our evaluation, machine learning-based EliIE outperforms existing systems and shows promise to improve.

PURPOSE:The analysis of exosome/microvesicle (extracellular vesicles (EVs)) and the RNA packaged within them (exoRNA) has the potential to provide a non-invasive platform to detect and monitor disease related gene expression potentially in lieu of more invasive procedures such as biopsy. However, few studies have tested the diagnostic potential of EV analysis in humans. EXPERIMENTAL DESIGN:The ability of EV analysis to accurately reflect prostate tissue mRNA expression was examined by comparing urinary EV TMPRSS2:ERG exoRNA from pre-radical prostatectomy (RP) patients versus corresponding RP tissue in 21 patients. To examine the differential expression of TMPRSS2:ERG across patient groups a random urine sample was taken without prostate massage from a cohort of 207 men including prostate biopsy negative (Bx Neg, n = 39), prostate biopsy positive (Bx Pos, n = 47), post-radical prostatectomy (post-RP, n = 37), un-biopsied healthy age-matched men (No Bx, n = 44), and young male controls (Cont, n = 40). The use of EVs was also examined as a potential platform to non-invasively differentiate Bx Pos versus Bx Neg patients via the detection of known prostate cancer genes TMPRSS2:ERG, BIRC5, ERG, PCA3 and TMPRSS2. RESULTS:In this technical pilot study urinary EVs had a sensitivity: 81% (13/16), specificity: 80% (4/5) and an overall accuracy: 81% (17/21) for non-invasive detection of TMPRSS2:ERG versus RP tissue. The rate of TMPRSS2:ERG exoRNA detection was found to increase with age and the expression level correlated with Bx Pos status. Receiver operator characteristic analyses demonstrated that various cancer-related genes could differentiate Bx Pos from Bx Neg patients using exoRNA isolated from urinary EVs: BIRC5 (AUC 0.674 (CI:0.560-0.788), ERG (AUC 0.785 (CI:0.680-0.890), PCA3 (AUC 0.681 (CI:0.567-0.795), TMPRSS2:ERG (AUC 0.744 (CI:0.600-0.888), and TMPRSS2 (AUC 0.637 (CI:0.519-0.754). CONCLUSION:This pilot study suggests that urinary EVs have the potential to be used as a platform to non-invasively differentiate patients with prostate cancer with very good accuracy. Larger studies are needed to confirm the potential for clinical utility.

OBJECTIVE:To apply cognitive task analyses of the Biomedical query mediation (BQM) processes for EHR data retrieval at multiple sites towards the development of a generic BQM process model. MATERIALS AND METHODS:We conducted semi-structured interviews with eleven data analysts from five academic institutions and one government agency, and performed cognitive task analyses on their BQM processes. A coding schema was developed through iterative refinement and used to annotate the interview transcripts. The annotated dataset was used to reconstruct and verify each BQM process and to develop a harmonized BQM process model. A survey was conducted to evaluate the face and content validity of this harmonized model. RESULTS:The harmonized process model is hierarchical, encompassing tasks, activities, and steps. The face validity evaluation concluded the model to be representative of the BQM process. In the content validity evaluation, out of the 27 tasks for BQM, 19 meet the threshold for semi-valid, including 3 fully valid: "Identify potential index phenotype," "If needed, request EHR database access rights," and "Perform query and present output to medical researcher", and 8 are invalid. DISCUSSION:We aligned the goals of the tasks within the BQM model with the five components of the reference interview. The similarity between the process of BQM and the reference interview is promising and suggests the BQM tasks are powerful for eliciting implicit information needs. CONCLUSIONS:We contribute a BQM process model based on a multi-site study. This model promises to inform the standardization of the BQM process towards improved communication efficiency and accuracy.

Electronic health records (EHR) are a vital data resource for research uses, including cohort identification, phenotyping, pharmacovigilance, and public health surveillance. To realize the promise of EHR data for accelerating clinical research, it is imperative to enable efficient and autonomous EHR data interrogation by end users such as biomedical researchers. This paper surveys state-of-art approaches and key methodological considerations to this purpose. We adapted a previously published conceptual framework for interactive information retrieval, which defines three entities: user, channel, and source, by elaborating on channels for query formulation in the context of facilitating end users to interrogate EHR data. We show the current progress in biomedical informatics mainly lies in support for query execution and information modeling, primarily due to emphases on infrastructure development for data integration and data access via self-service query tools, but has neglected user support needed during iteratively query formulation processes, which can be costly and error-prone. In contrast, the information science literature has offered elaborate theories and methods for user modeling and query formulation support. The two bodies of literature are complementary, implying opportunities for cross-disciplinary idea exchange. On this basis, we outline the directions for future informatics research to improve our understanding of user needs and requirements for facilitating autonomous interrogation of EHR data by biomedical researchers. We suggest that cross-disciplinary translational research between biomedical informatics and information science can benefit our research in facilitating efficient data access in life sciences.

OBJECTIVES:The Patient, Intervention, Control/Comparison, and Outcome (PICO) framework is an effective technique for framing a clinical question. We aim to develop the counterpart of PICO to structure clinical research data needs.METHODS:We use a data-driven approach to abstracting key concepts representing clinical research data needs by adapting and extending an expert-derived framework originally developed for defining cancer research data needs. We annotated clinical trial eligibility criteria, EHR data request logs, and data queries to electronic health records (EHR), to extract and harmonize concept classes representing clinical research data needs. We evaluated the class coverage, class preservation from the original framework, schema generalizability, schema understandability, and schema structural correctness through a semi-structured interview with eight multidisciplinary domain experts. We iteratively refined the schema based on the evaluations.RESULTS:Our data-driven schema preserved 68% of the 63 classes from the original framework and covered 88% (73/82) of the classes proposed by evaluators. Class coverage for participants of different backgrounds ranged from 60% to 100% with a median value of 95% agreement among the individual evaluators. The schema was found understandable and structurally sound.CONCLUSIONS:Our proposed schema may serve as the counterpart to PICO for improving the research data needs communication between researchers and informaticians.

BACKGROUND We sought to determine maximum wait times between biopsy diagnosis and surgery for localized prostate cancer, beyond which the rate of adverse pathologic outcomes is increased. METHODS We retrospectively reviewed 4,610 patients undergoing radical prostatectomy between 1990 and 2011. Patients were stratified by biopsy Gleason score and PSA value. For each stratification, χ 2 analysis was used to determine the smallest 15‐day multiple of surgical delay (e.g., 15, 30, 45…180 days) for which adverse pathologic outcomes were significantly more likely after the time interval than before. Adverse outcomes were defined as positive surgical margins, upgrading from biopsy, upstaging, seminal vesicle invasion, or positive lymph nodes. RESULTS Two thousand two hundred twelve patients met inclusion criteria. Median delay was 64 days (mean 76, SD 47). One thousand six hundred seventy‐five (75.7%), 537 (24.3%), and 60 (2.7%) patients had delays of <=90, >90, and >180 days, respectively. Twenty‐six percent were upgraded on final pathology and 23% were upstaged. The positive surgical margin rate was 24.2% and the positive lymph node rate was 1.1%. Significant increases in the proportion of adverse pathological outcomes were found beyond 75 days in the overall cohort ( P = 0.03), 150 days for patients with Gleason <=6, and PSA 0–10 ( P = 0.038), 60 days for patients with Gleason 7 and PSA >20 ( P = 0.032), and 30 days for patients with Gleason 8–10 and PSA 11–20 (0.041). CONCLUSION In low‐risk disease, there is a considerable but not unlimited surgical delay which will not adversely impact the rate of adverse pathologic features found. In higher risk disease, this time period is considerably shorter. Prostate 75:1085–1091, 2015 . © 2015 Wiley Periodicals, Inc.

The lack of understanding of user experience with self-service query tools is a barrier to designing effective query tools and is what propelled this study. User actions were documented and transformed into networks of actions for qualitative analysis. Proficient use of self-service query tools requires significant technical experience. To decrease the user learning curve, additional user education is necessary for novice users.

INTRODUCTION:Involvement of the prostatic urethra by bladder cancer directly impacts prognosis, risk of urethral recurrence, and timing of radical cystectomy (RC); it also affects the type of urinary diversion chosen. Both cold cup biopsies and transurethral (TUR) loop biopsies have been used to evaluate the status of the prostatic urethra. We report our 20 year experience with preoperative and intro-operative prostatic urethral biopsies in order to determine relative efficacy and associated treatment implications. MATERIALS AND METHODS:The Columbia University urologic oncology database was reviewed and yielded 234 men who underwent preoperative endoscopic biopsies of the prostatic urethra before RC between 1990 and 2010. Two techniques were described: 1) cold cup biopsy, and 2) TUR loop biopsy. We evaluated the sensitivity, specificity, and predictive values for these respective techniques relative to the final pathological status of the prostatic urethra (PU) in the RC specimen. RESULTS:Of the 234 urethral biopsies 115 (49.1%) were cold cup and 96 (41.1%) were TUR loop biopsies. In the remaining 9.8% of patients, the technique could not be determined. Eighty-one preoperative biopsies (34.6%) revealed involvement of the urethra. No differences were observed in predictive values, sensitivity, and specificity between the two preoperative techniques. The negative predictive value (NPV) was higher than positive predictive value (PPV) for both preoperative approaches. Thirty-eight patients (16.2%) had a urethral frozen section analysis done intra-operatively. Only 1 patient (3%) had an abnormality on frozen section, being the negative predictive value (NPV) higher than the positive predictive value (PPV) for the test's ability to predict the status of the final urethral margin. Urethrectomy was performed at cystectomy in 52 patients with a positive biopsy; 15 (28.8%) of these patients ultimately had a negative PU on final pathology. Only 2/182 (1%) of the patients with an intact urethra presented with a urethral recurrence with a median follow up of 30.5 months. CONCLUSIONS:Preoperative prostatic urethral biopsy does not adequately predict final prostatic urethral status at radical cystectomy. No differences in predictive capacity could be detected with either cold cup biopsy or TUR biopsy. Intra-operative biopsy of the prostatic urethra is predictive of a negative urethral margin. Simultaneous radical urethrectomy should not be performed based up on preoperative prostatic urethral biopsy results alone.