PURPOSE:While the presence of residual disease at the time of radical cystectomy for bladder cancer is an established prognostic indicator, controversy remains regarding the importance of maximal transurethral resection prior to neoadjuvant chemotherapy. We characterized the influence of maximal transurethral resection on pathological and survival outcomes using a large, multi-institutional cohort.MATERIALS AND METHODS:We identified 785 patients from a multi-institutional cohort undergoing radical cystectomy for muscle-invasive bladder cancer after neoadjuvant chemotherapy. We employed bivariate comparisons and stratified multivariable models to quantify the effect of maximal transurethral resection on pathological findings at cystectomy and survival.RESULTS:Of 785 patients, 579 (74%) underwent maximal transurethral resection. Incomplete transurethral resection was more frequent in patients with more advanced clinical tumor (cT) and nodal (cN) stage (P < .001 and P < .01, respectively), with more advanced ypT stage at cystectomy and higher rates of positive surgical margins (P < .01 and P < .05, respectively). In multivariable models, maximal transurethral resection was associated with downstaging at cystectomy (adjusted odds ratio 1.6, 95% CI 1.1-2.5). In Cox proportional hazards analysis, maximal transurethral resection was not associated with overall survival (adjusted HR 0.8, 95% CI 0.6-1.1).CONCLUSIONS:In patients undergoing transurethral resection for muscle-invasive bladder cancer prior to neoadjuvant chemotherapy, maximal resection may improve pathological response at cystectomy. However, the ultimate effects on long-term survival and oncologic outcomes warrant further investigation.

INTRODUCTION:µ-Opioid-receptor antagonists are a standard component of enhanced recovery after surgery (ERAS) pathways following radical cystectomy (RC) as they reduce ileus and shorten length of stay (LOS). Prior studies have used alvimopan; however, naloxegol is a less expensive medication in the same class. We compared differences in postoperative outcomes between patients receiving alvimopan or naloxegol following RC. METHODS:We retrospectively reviewed all patients undergoing RC over 20 months at an academic center during which standard practice transitioned from using alvimopan to naloxegol, while maintaining all other components of our ERAS pathway. We utilized bivariate comparisons as well as negative binomial and logistic regression to compare return of bowel function, rates of ileus and LOS following RC. RESULTS:Of 117 eligible patients, 59 (50%) received alvimopan and 58 (50%) received naloxegol. There were no differences in baseline clinical, demographic or perioperative factors. Median postoperative LOS was 6 days in each group (p=0.3). Time to flatus (2 versus 2 days, p=0.2) and ileus (14% versus 17%, p=0.6) were similar between the alvimopan and naloxegol groups, respectively. In multivariable models controlling for patient and surgical factors, µ-opioid antagonist agent was associated with neither LOS nor ileus. Cost difference was -$344.20/day, equivalent to a $2,065.20 savings over a 6-day hospital stay with naloxegol. CONCLUSIONS:In patients undergoing RC managed with a standard ERAS pathway, there were no differences in postoperative recovery based on the use of alvimopan versus naloxegol. Substitution of naloxegol for alvimopan may allow for significant cost savings without compromising outcomes.

Maintaining men on active surveillance for prostate cancer can be challenging. Although most men who eventually undergo treatment have experienced clinical progression, a smaller subset elects treatment in the absence of disease reclassification. This study sought to understand factors associated with treatment in a large, contemporary, prospective cohort.

Background After release of the Comprehensive Care for Joint Replacement bundle, there has been increased emphasis on reducing readmission rates for total knee arthroplasty (TKA). The potential for a separate, clinically-relevant metric, TKA revision rates within a year following surgery, has not been fully explored. Based on this, we compared rates and payments for TKA readmission and revision procedures as metrics for improving quality and cost. Methods We utilized the 2013 Nationwide Readmission Database (NRD) to examine national readmission and revision rates, the reasons for revision procedures, and associated costs for elective TKA procedures. As data are not linked across years, we examined revision rates for TKA completed in the month of January by capturing revision procedures in the subsequent following 11-month period to approximate a 1-year revision rate. Diagnosis and procedure codes for revision procedures were collected. Average readmission and revision procedure costs were then calculated, and the cost distributed across the entire TKA population. Results We identified 20,851 patients having TKA surgery. The mean unadjusted 30- and 90-day TKA readmission rates were 3.4% and 5.8%, respectively. In contrast, the mean unadjusted 3-month and approximate 1-year reoperation rates were 1.0% and 1.6%, respectively. The most common cause for revision was periprosthetic joint infection, which accounting for 62% of all reported revision procedures. The mean payment for 90-day readmission was roughly half ($10,589±$11,084) of the mean inpatient payment for single reoperation procedure at 90 days ($20,222±$17,799). Importantly, nearly half (46%) of all 90-day readmissions were associated with a reoperation event within the first year. Conclusions Readmission following TKA is associated with a 1-year reoperation in approximately half of patients. These reoperations represent a significant patient burden and have a higher per episode cost. Early reoperation may represent a more clinically relevant target for quality improvement and cost containment.

Objective: To determine if the addition of electronic health record data enables better risk stratification and readmission prediction after radical cystectomy. Despite efforts to reduce their frequency and severity, complications and readmissions following radical cystectomy remain common. Leveraging readily available, dynamic information such as laboratory results may allow for improved prediction and targeted interventions for patients at risk of readmission. Methods: We used an institutional electronic medical records database to obtain demographic, clinical, and laboratory data for patients undergoing radical cystectomy. We characterized the trajectory of common postoperative laboratory values during the index hospital stay using support vector machine learning techniques. We compared models with and without laboratory results to assess predictive ability for readmission. Results: Among 996 patients who underwent radical cystectomy, 259 patients (26%) experienced a readmission within 30 days. During the first week after surgery, median daily values for white blood cell count, urea nitrogen, bicarbonate, and creatinine differentiated readmitted and nonreadmitted patients. Inclusion of laboratory results greatly increased the ability of models to predict 30-day readmissions after cystectomy. Conclusions: Common postoperative laboratory values may have discriminatory power to help identify patients at higher risk of readmission after radical cystectomy. Dynamic sources of physiological data such as laboratory values could enable more accurate identification and targeting of patients at greatest readmission risk after cystectomy. This is a proof of concept study that suggests further exploration of these techniques is warranted. (C) 2019 Elsevier Inc. All rights reserved.

OBJECTIVE:To examine population-based practice patterns and outcomes related to urethroplasty for urethral stricture management.METHODS:We conducted a retrospective study of adult males with urethral stricture disease treated from January 2001 to June 2015 using the Clinformatics Data Mart Database. Treatment was defined as urethral dilation, direct visualized internal urethrotomy, and urethroplasty. We then examined anterior or posterior urethroplasty outcomes defining failure as any subsequent procedure specific to urethral stricture disease occurring >30 days after urethroplasty. We used multivariable and time-to-event analysis to examine factors associated with failure.RESULTS:We identified 75,666 patients treated for urethral stricture disease, with 420 and 367 undergoing anterior and posterior urethroplasty, respectively. Urethroplasty utilization doubled from 2005 to 2015. One- and 5-year failure rates for anterior and posterior urethroplasty were 25% and 18%, and 40% and 25%, respectively, with median times to failure of 5.1 and 4.1 months. Failures were salvaged primarily with direct visualized internal urethrotomy, with salvage urethroplasty in 19% and 12% of anterior and posterior repairs, respectively.CONCLUSION:Despite increasing population-based urethroplasty utilization over the past decade in our insured cohort, we found higher rates of salvage treatments than reported by high-volume and expert surgeon reports. Further efforts appear warranted to balance workforce expertise and quality of urethroplasty care to meet increasing urethral stricture population needs.

OBJECTIVE:To examine predictors of early readmissions after radical cystectomy (RC). Factors associated with preventable readmissions may be most evident in readmissions that occur within 3 days of discharge, commonly termed 'bounce-back' readmissions, and identifying such factors may inform efforts to reduce surgical readmissions.PATIENTS AND METHODS:We utilised the Healthcare Cost and Utilization Project's State Inpatient Databases to examine 1867 patients undergoing RC in 2009 and 2010, and identified all patients readmitted within 30 days of discharge. We assessed differences between patients experiencing bounce-back readmission compared to those readmitted 8-30 days after discharge using logistic regression models and also calculated abbreviated LACE scores to assess the utility of common readmissions risk stratification algorithms.RESULTS:The 30-day and bounce-back readmission rates were 28.4% and 5.6%, respectively. Although no patient or index hospitalisation characteristics were significantly associated with bounce-back readmissions in adjusted analyses, bounce-back patients did have higher rates of gastrointestinal (14.3% vs 6.7%, P = 0.02) and wound (9.5% vs 3.0%, P < 0.01) diagnoses, as well as increased index and readmission length of stay (5 vs 4 days, P = 0.01). Overall, the median abbreviated LACE score was 7, which fell into the moderate readmission risk category, and no difference was observed between readmitted and non-readmitted patients.CONCLUSION:One in five readmissions after RC occurs within 3 days of initial discharge, probably due to factors present at discharge. However, sociodemographic and clinical factors, as well as traditional readmission risk tools were not predictive of this bounce-back. Effective strategies to reduce bounce-back readmission must identify actionable clinical factors prior to discharge.

ObjectivesTo characterise bone scan use, and potential overuse, after radical prostatectomy (RP) using data from a large, national integrated delivery system. Overuse of imaging is well documented in the setting of newly diagnosed prostate cancer, but whether overuse persists after RP remains unknown.Patients and methodsWe identified 12 269 patients with prostate cancer treated with RP between 2005 and 2008 using the Veterans Administration Central Cancer Registry. We used administrative and laboratory data to examine rates of bone scan use, including preceding prostate‐specific antigen (PSA) levels, and receipt of adjuvant or salvage therapy. We then performed multivariable logistic regression to identify factors associated with post‐RP bone scan use.ResultsAt a median follow‐up of 6.8 years, one in five men (22%) underwent a post‐RP bone scan at a median PSA level of 0.2 ng/mL. Half of bone scans (48%) were obtained in men who did not receive further treatment with androgen‐deprivation or radiation therapy. After adjustment, post‐RP bone scan was associated with a prior bone scan (adjusted odds ratio [aOR] 1.55, 95% confidence interval [CI] 1.32–1.84), positive surgical margin (aOR 1.68, 95% CI 1.40–2.01), preoperative PSA level (aOR 1.02, 95% CI 1.01–1.03), as well as Hispanic ethnicity, Black race, and increasing D'Amico risk category, but not with age or comorbidity.ConclusionWe found a substantial rate of bone scan utilisation after RP. The majority were performed for PSA levels of <1 ng/mL where the likelihood of a positive test is low. More judicious use of imaging appears warranted in the post‐RP setting.

You have accessJournal of UrologyBladder Cancer: Epidemiology & Evaluation II1 Apr 2018MP71-02 REFRAMING READMISSION REDUCTION INCENTIVES AFTER RADICAL CYSTECTOMY Michael Sessine, Tudor Borza, Alon Weizer, Peter Kirk, Xiang Liu, Benjamin Li, Brent Hollenbeck, Yongmei Qin, Bruce Jacobs, Ken Urish, Jonathan Helm, Mariel Lavieri, and Ted Skolarus Michael SessineMichael Sessine More articles by this author , Tudor BorzaTudor Borza More articles by this author , Alon WeizerAlon Weizer More articles by this author , Peter KirkPeter Kirk More articles by this author , Xiang LiuXiang Liu More articles by this author , Benjamin LiBenjamin Li More articles by this author , Brent HollenbeckBrent Hollenbeck More articles by this author , Yongmei QinYongmei Qin More articles by this author , Bruce JacobsBruce Jacobs More articles by this author , Ken UrishKen Urish More articles by this author , Jonathan HelmJonathan Helm More articles by this author , Mariel LavieriMariel Lavieri More articles by this author , and Ted SkolarusTed Skolarus More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.2266AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Radical cystectomy has one of the highest treatment costs of any major cancer surgery and one of the highest readmission rates, also contributing to overall cost. Policy penalties in select surgery types have removed financial incentives associated with readmissions, but the extent of these incentives for most major cancer surgery remains unclear. Our study examined national payment trends for readmissions following radical cystectomy and the degree to which hospitals may financially benefit from readmissions. METHODS We identified 388 patients from our institutional bladder cancer database and queried institutional accounting data for estimated revenue and direct costs for each encounter. Our primary outcome was direct margin among readmitted and non-readmitted patients, measured as the difference between estimated revenue and direct costs. To understand population-based readmission payment trends, we also compared Medicare price-standardized payments for 3,544 national beneficiaries undergoing radical cystectomy according to readmission status. RESULTS Overall, 19.8% of patients (n=77) were readmitted to our institution following radical cystectomy, generating an average direct margin of $13,811 compared to $8,546 for non-readmitted patients (Table). The readmission rate for the Medicare cohort was 26.9% (n=936), with Medicare payments for the index hospitalization significantly higher for readmitted patients ($19,164 readmitted vs. $18,146 non-readmitted, p=0.03). The average Medicare payment for the first readmission within 30 days was $7,356. CONCLUSIONS Readmission following radical cystectomy increased the average direct margin per patient, potentially limiting incentives for hospitals to invest in readmission reduction programs. While better understanding readmission billing patterns after major cancer surgery is warranted, reframing incentives towards optimizing the discharge and readmission experiences, rather than pursuing traditional fiscal policy incentives, should be considered. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e943 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Michael Sessine More articles by this author Tudor Borza More articles by this author Alon Weizer More articles by this author Peter Kirk More articles by this author Xiang Liu More articles by this author Benjamin Li More articles by this author Brent Hollenbeck More articles by this author Yongmei Qin More articles by this author Bruce Jacobs More articles by this author Ken Urish More articles by this author Jonathan Helm More articles by this author Mariel Lavieri More articles by this author Ted Skolarus More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

BACKGROUND:Payment models, including the Hospital Readmissions Reduction Program and bundled payments, place pressures on hospitals to limit readmissions. Against this backdrop, we sought to investigate the association of post-acute care after major surgery and readmission rates. METHODS:We identified patients undergoing high-risk surgery (abdominal aortic aneurysm repair, coronary bypass grafting, aortic valve replacement, carotid endarterectomy, esophagectomy, pancreatectomy, lung resection, and cystectomy) from 2005 to 2010 using the Healthcare Cost and Utilization Project's State Inpatient Database. The primary outcome was readmission rates after major surgery. Secondary outcome was readmission length of stay. RESULTS:We identified 135,523 patients of whom 56,720 (42%) received post-acute care. Patients receiving post-acute care had higher readmission rates than those who were discharged home (16% versus 10%, respectively; P < 0.001). The risk-adjusted readmission length of stay was greatest for patients who received care from a skilled nursing facility, followed by those who received home care, and lowest for those who did not receive post-acute care (7.1 versus 5.4 versus 4.8 d, respectively; P < 0.001). CONCLUSIONS:The use of post-acute care was associated with higher readmission rates and higher readmission lengths of stay. Improving the support of patients in post-acute care settings may help reduce readmissions and readmission intensity.

You have accessJournal of UrologyBladder Cancer: Epidemiology & Evaluation II1 Apr 2018MP71-04 ASSESSING LABORATORY PARAMETERS AND READMISSIONS AFTER RADICAL CYSTECTOMY Peter Kirk, Xiang Liu, Tudor Borza, Benjamin Li, Michael Sessine, Kevin Zhu, Yongmei Qin, Bruce Jacobs, Ken Urish, Jonathan Helm, Scott Gilbert, Alon Weizer, Jeffrey Montgomery, Brent Hollenbeck, Mariel Lavieri, and Ted Skolarus Peter KirkPeter Kirk More articles by this author , Xiang LiuXiang Liu More articles by this author , Tudor BorzaTudor Borza More articles by this author , Benjamin LiBenjamin Li More articles by this author , Michael SessineMichael Sessine More articles by this author , Kevin ZhuKevin Zhu More articles by this author , Yongmei QinYongmei Qin More articles by this author , Bruce JacobsBruce Jacobs More articles by this author , Ken UrishKen Urish More articles by this author , Jonathan HelmJonathan Helm More articles by this author , Scott GilbertScott Gilbert More articles by this author , Alon WeizerAlon Weizer More articles by this author , Jeffrey MontgomeryJeffrey Montgomery More articles by this author , Brent HollenbeckBrent Hollenbeck More articles by this author , Mariel LavieriMariel Lavieri More articles by this author , and Ted SkolarusTed Skolarus More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.2268AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Despite efforts to reduce their frequency and severity, complications and readmissions following radical cystectomy remain common. Identifying patients at highest readmission risk using traditional administrative data is difficult. Leveraging readily available, dynamic information such as laboratory values may allow for improved prediction and targeted interventions for at-risk patients. METHODS We used an institutional electronic medical records database to obtain demographic, clinical, and laboratory data for patients undergoing radical cystectomy during a 10 year period (2006-2016). We characterized the trajectory of laboratory values obtained in complete blood counts, basic metabolic panels, and coagulation studies during the index hospital stay. We then applied support vector machine (SVM) learning techniques, and compared the variance of laboratory parameters to assess differences between readmitted and non-readmitted patients. RESULTS We identified 1,034 patients who underwent radical cystectomy during the study period. 220 (21%) patients experienced a readmission within 30 days of discharge. The mean patient age was 66.7 years, and average Charlson Comorbidity score was 3.3. We found that the median daily values for white blood cell count (WBC), urea nitrogen (BUN), bicarbonate (CO2), and creatinine differentiated readmitted and non-readmitted patients during the week after surgery (Figure). Glucose levels demonstrated differentiation among patients remaining in the hospital greater than one week. Comparisons of electrolyte levels and coagulation parameters did not discriminate among readmitted and non-readmitted patients. In addition, WBC and BUN also had significantly greater variance among readmitted than non-readmitted patients (p <0.05 for both). Chloride had significantly greater variance within readmitted patients (p <0.001), but did not clearly distinguish between groups. CONCLUSIONS Commonly measured postoperative laboratory values may have discriminatory power to help identify patients at high risk of readmission after radical cystectomy. Incorporating readily available, dynamic sources of physiological data such as laboratory values into prediction algorithms could enable more accurate identification and targeting of patients at greatest readmission risk. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e944 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Peter Kirk More articles by this author Xiang Liu More articles by this author Tudor Borza More articles by this author Benjamin Li More articles by this author Michael Sessine More articles by this author Kevin Zhu More articles by this author Yongmei Qin More articles by this author Bruce Jacobs More articles by this author Ken Urish More articles by this author Jonathan Helm More articles by this author Scott Gilbert More articles by this author Alon Weizer More articles by this author Jeffrey Montgomery More articles by this author Brent Hollenbeck More articles by this author Mariel Lavieri More articles by this author Ted Skolarus More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

OBJECTIVE To determine the impact of physicians' financial relationships with the pharmaceutical industry on prescribing marketed alpha-blockers and overactive bladder (OAB) medications. We also aim to examine if the number or total value of transactions is influential. MATERIALS AND METHODS We linked the Open Payments Program database of industry payments to prescribers with Medicare Part D prescription data. We used binomial logistic regression to identify the association between receipt of industry payment and prescribing of marketed alpha-blockers (silodosin) and OAB medications (fesoterodine, solifenacin, and mirabegron). We also evaluated the impact of increasing total value and number of payments on prescribing of marketed drugs. RESULTS The receipt of industry payment was associated with increased odds of prescribing the marketed drug for all included drugs: silodosin (odds ratio [OR] 34.1), fesoterodine (OR 5.9), solifenacin (OR 2.7), and mirabegron (OR 6.8) (all P < .001). We also found that increasing value of total payment and increasing frequency of payments were both independently associated with increased odds of prescribing with a dose-response effect. CONCLUSION There is a consistent association between receipt of industry payment and prescribing marketed alpha-blockers and OAB medications. Both the total value and number of transactions were associated with prescribing. (c) 2018 Elsevier Inc.

AimsThe use of cystoscopy and hydrodistention in the management of interstitial cystitis/bladder pain syndrome (IC/BPS) varies widely between providers. Current evidence regarding the risks and benefits of hydrodistention, as well as the long term effects of repeated hydrodistention are not well established. We sought to characterize the effects of hydrodistention on IC/BPS symptoms as well as bladder capacity.MethodsWe retrospectively queried our institutional records for patients with non‐ulcerative IC/BPS who underwent hydrodistention over an 11‐year period to obtain demographic and clinical factors at the time of diagnosis and treatment. Symptom relief and bladder capacity changes were assessed, and multivariable models were used to predict response to treatment.ResultsThere were 328 patients who underwent hydrodistention during the study period, of whom 36% received the procedure multiple times, and overall median follow‐up was 38.6 months. Patients with repeated hydrodistentions were more likely to be female, have more comorbid pain disorders, and have trialed anticholinergic medications and intravesical instillations. No decrease in mean bladder capacity was observed over time (P = 0.40). Significant decreases in symptom scores were observed following the procedure on multiple questionnaires.ConclusionsHydrodistention does not decrease bladder capacity even with multiple procedures, and measurably improves symptoms in some patients with IC/BPS. Continuing efforts to better identify those patients most likely to benefit from this procedure are justified.

Background The Comprehensive Care for Joint Replacement bundle was created to decrease total knee arthroplasty (TKA) cost. To help accomplish this, there is a focus on reducing TKA readmissions. However, there is a lack of national representative sample of all-payer hospital admissions to direct strategy, identify risk factors for readmission, and understand actual readmission cost. Methods We used the Nationwide Readmission Database to examine national readmission rates, predictors of readmission, and associated readmission costs for elective TKA procedures. We fit a multivariable logistic regression model to examine factors associated with readmission. Then, we determined mean readmission costs and calculated the readmission cost when distributed across the entire TKA population. Results We identified 224,465 patients having TKA across all states participating in the Nationwide Readmission Database. The mean unadjusted 30-day TKA readmission rate was 4%. The greatest predictors of readmission were congestive heart failure (odds ratio [OR] 2.51, 95% confidence interval [CI] 2.62-2.80), renal disease (OR 2.19, 95% CI 2.03-2.37), and length of stay greater than 4 days (OR 2.4, 95% CI 2.25-2.61). The overall median cost for each readmission was $6753 ± 175. Extrapolating the readmission cost for the entire TKA population resulted in the readmission cost being 2% of the overall 30-day procedure cost. Conclusions A major focus of the Comprehensive Care for Joint Replacement bundle is improving cost and quality by limiting readmission rates. TKA readmissions are low and comprise a small percentage of total TKA cost, suggesting that they may not be the optimal measure of quality care or a significant driver of overall cost.

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Value of Care: Cost and Outcomes Measures I1 Apr 2017PD14-05 ECONOMIC IMPLICATIONS OF UROLOGIST PRESCRIPTION PRACTICES AMONG MEDICARE PART D BENEFICIARIES Peter Kirk, Tudor Borza, James Dupree, John Wei, Chad Ellimoottil, Megan Caram, Brent Hollenbeck, and Ted Skolarus Peter KirkPeter Kirk More articles by this author , Tudor BorzaTudor Borza More articles by this author , James DupreeJames Dupree More articles by this author , John WeiJohn Wei More articles by this author , Chad EllimoottilChad Ellimoottil More articles by this author , Megan CaramMegan Caram More articles by this author , Brent HollenbeckBrent Hollenbeck More articles by this author , and Ted SkolarusTed Skolarus More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.706AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Millions of patients take prescription medications each year for common urologic conditions. Generic and brand name drugs often have widely divergent pricing despite similar therapeutic benefit and side effect profiles. Because prescriptions will only increase as the US population ages, we examined urologist prescription patterns for generic and brand name drugs used to treat three common urologic conditions, and consequent economic implications for Medicare Part D spending. METHODS We extracted all 2014 urologist prescription claims and payments from the Medicare Part D Prescriber Public Use File. We categorized oral medications used to treat three urological conditions: benign prostate enlargement, erectile dysfunction, and overactive bladder. We then examined total claims, payments, and 30 day cost for each medication with at least 1,000 prescription claims. Last, we estimated the excess annual Medicare Part D payments associated with use of non generic and higher cost medications. We selected a low cost and/or generic drug as a cost comparator for each drug class, then calculated the difference between the actual cost of non comparator drugs and the cost of equivalent length prescriptions of the comparator. RESULTS The total claims, total payments, and 30 day cost for medications by urologic condition are shown (Table). Within drugs for benign prostate enlargement, the excess Medicare Part D payment for drugs other than generic tamsulosin or finasteride was $158,935,926. Among erectile dysfunction medications, the excess payment for drugs other than Levitra was $3,105,023. Within drugs for overactive bladder, the excess payment for drugs other than generic oxybutynin extended-release was $248,430,484. The total excess Medicare Part D prescription payment for higher cost and non generic drugs prescribed by urologists in 2014 was $410,471,433. CONCLUSIONS Among Medicare Part D beneficiaries, we found excess payments for higher cost and non generic drugs prescribed by urologists for three common conditions approached a half billion US dollars. Increasing low cost and generic drug use where available evidence is equivocal represents a promising policy target to reduce Part D medication spending. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e278 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Peter Kirk More articles by this author Tudor Borza More articles by this author James Dupree More articles by this author John Wei More articles by this author Chad Ellimoottil More articles by this author Megan Caram More articles by this author Brent Hollenbeck More articles by this author Ted Skolarus More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Urethral Reconstruction (including Stricture, Diverticulum) IV1 Apr 2017PD60-11 POPULATION-BASED MANAGEMENT OF MALE URETHRAL STRICTURE DISEASE Robert Goldfarb, Steven Brandes, Peter Kirk, Tudor Borza, Yongmei Qin, and Ted Skolarus Robert GoldfarbRobert Goldfarb More articles by this author , Steven BrandesSteven Brandes More articles by this author , Peter KirkPeter Kirk More articles by this author , Tudor BorzaTudor Borza More articles by this author , Yongmei QinYongmei Qin More articles by this author , and Ted SkolarusTed Skolarus More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.2757AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Male urethral stricture disease is a common condition with significant quality of life and economic implications. While endoscopic treatment with incision or dilation is the most common treatment approach, the AUA guidelines (www.auanet.org/guidelines) recommend urethroplasty based on increased long-term success rates. However, the extent to which this procedure is performed relative to endoscopic treatment in real-world practice in the USA is unknown. Thus, we conducted a population-based study of patients treated for urethral stricture disease to examine management patterns and opportunities for improvement. METHODS We identified male patients who underwent procedures for urethral stricture disease between 2001 and June 2015 based on ICD-9 codes and administrative claims from a large, national US health insurer (ClinformaticsTM Data Mart Database, Optum Insight, Eden Prairie, MN). We assessed utilization and standardized cost of endoscopic treatments (urethrotomy and dilation) and urethroplasty. We examined patient factors associated with endoscopic treatment versus urethroplasty using multivariable logistic regression. RESULTS We identified a total of 75,522 patients treated for male urethral stricture disease with 125,498 total procedures. This is the largest reported cohort of urethral stricture procedures in the literature. The majority of patients were treated with endoscopic surgery (98.8%), with only 1,515 patients undergoing urethroplasty. After adjustment, younger age (adjusted odds ratio (aOR), age ≤ 40 vs. age ≥ 60 years, 8.2; 95% CI, 7.2-9.4) and higher annual income (aOR, income ≤ $40K vs. ≥ $100,00K, 0.7; 95% CI, 0.5-0.9) were each associated with receipt of urethroplasty. Total standardized costs for endoscopic treatment was $115,724,899 compared to $3,678,066 for urethroplasty. CONCLUSIONS Our population-based study of insured patients demonstrated very low use of urethroplasty in real-world practice, despite recommendations for use and superior success rates. Income disparities in urethroplasty utilization is concerning and may indicate health access disparity. Strategies to increase the use of high value surgery for patients with urethral stricture disease include increasing referrals to reconstructive urologists, and knowledge and technique transfer to community urologists interested in providing this service rather than repeated, low-value endoscopic treatment. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e1186-e1187 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Robert Goldfarb More articles by this author Steven Brandes More articles by this author Peter Kirk More articles by this author Tudor Borza More articles by this author Yongmei Qin More articles by this author Ted Skolarus More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

You have accessJournal of UrologyInfections/Inflammation/Cystic Disease of the Genitourinary Tract: Interstitial Cystitis I1 Apr 2017PD01-10 EFFECTS OF REPEAT HYDRODISTENTION FOR INTERSTITIAL CYSTITIS Peter Kirk, Yahir Santiago-Lastra, John Stoffel, J Quentin Clemens, and Anne Pelletier Cameron Peter KirkPeter Kirk More articles by this author , Yahir Santiago-LastraYahir Santiago-Lastra More articles by this author , John StoffelJohn Stoffel More articles by this author , J Quentin ClemensJ Quentin Clemens More articles by this author , and Anne Pelletier CameronAnne Pelletier Cameron More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.190AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Cystoscopy and hydrodistention is a therapeutic procedure for interstitial cystitis (IC) which achieves symptomatic relief in many patients, though its use varies widely between providers. The long term effects of repeated hydrodistention are not well understood and it is not known if patients suffer a reduction in bladder capacity due to these multiple procedures or develop ulcerating disease over time. We sought to investigate the effects of multiple hydrodistentions in patients with IC. METHODS We retrospectively queried our institutional records for patients without ulcerative disease who underwent 2 or more hydrodistentions for IC over a ten year period. Patient charts were reviewed for demographic and clinical factors at the time of diagnosis and treatment. RESULTS There were 97 patients who underwent multiple cystoscopy and hydrodistention procedures for non ulcerative IC during the ten year study period. The cohort was 98% female and 92% Caucasian. Mean age at diagnosis was 35.7 years, and mean BMI was 27.1. Average number of procedures performed was 3.7 (range 2 to 18), and mean time between procedures was 430.6 days. Within this cohort 63.3% of patients had at least 1 comorbid pain disorder. Mean initial and final anesthetic bladder capacity were 723.9cc and 753.1cc, respectively, which were not significantly different (p=0.15). One patient in this cohort later developed ulcerative disease which was not present at initial cystoscopy. Among patients who completed AUA symptom questionnaires before and after hydrodistention, both symptom and quality of life scores were significantly improved following treatment (17.1 vs 14.3, 4.3 vs 3.6, p <0.001 for both). The complication rate during the study period was 0.83% and comprised an extraperitoneal bladder perforation managed conservatively, anaphylaxis to DMSO instillation, and transient tachycardia with hypotension. CONCLUSIONS Repeated hydrodistention did not decrease bladder capacity over time and development of ulceration was rare. In this cohort of patients it had significant positive effects on symptom control and quality of life. Hydrodistention is a safe procedure with low complication rates. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e49-e50 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Peter Kirk More articles by this author Yahir Santiago-Lastra More articles by this author John Stoffel More articles by this author J Quentin Clemens More articles by this author Anne Pelletier Cameron More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Urethral Reconstruction (including Stricture, Diverticulum) III1 Apr 2017PD34-08 REAL-WORLD EFFECTIVENESS OUTCOMES FOR URETHROPLASTY Robert Goldfarb, Steven Brandes, Peter Kirk, Tudor Borza, Yongmei Qin, and Ted Skolarus Robert GoldfarbRobert Goldfarb More articles by this author , Steven BrandesSteven Brandes More articles by this author , Peter KirkPeter Kirk More articles by this author , Tudor BorzaTudor Borza More articles by this author , Yongmei QinYongmei Qin More articles by this author , and Ted SkolarusTed Skolarus More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1531AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Urethral stricture disease is common condition with significant quality of life and economic implications. While endoscopic treatment with incision or dilation is the most common treatment approach, guidelines increasingly recommend urethroplasty based on its high success rates. Whether real world, community practice outcomes mirror those of large volume single center institutional series is unknown. For these reasons, we conducted a population-based study of patients treated with urethroplasty and their outcomes. METHODS We identified male patients who underwent urethroplasty between 2001 and June 2015 based on ICD-9 codes and administrative claims from a large, national US health insurer (ClinformaticsTM Data Mart Database, OptumInsight, Eden Prairie, MN). We assessed utilization of endoscopic treatments (urethrotomy and dilation) prior to and after urethroplasty. We defined urethroplasty failure by any subsequent urethral dilation, urethrotomy, or urethroplasty after initial urethroplasty. We examined factors associated with failure using multivariable logistic regression and Cox proportional hazards models. RESULTS We identified 1345 patients treated with urethroplasty. Urethroplasty failure occurred in 344 (26%) of patients. Repeat urethroplasty was performed in 139 (40%) of failures (range 2-8). Increased number of endoscopic treatments prior to first urethroplasty was associated with urethroplasty failure. The mean (±SD) time to failure was 270 ± 42 days. CONCLUSIONS Our population-based study demonstrated significantly lower success rates for urethroplasty than previously published reports. Strategies to achieve better outcomes for patients with urethral stricture disease include increasing referrals to reconstructive urologic surgeons, and knowledge and technique transfer to community urologists interested in providing this service rather than repeated, low-value endoscopic treatment. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e660 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Robert Goldfarb More articles by this author Steven Brandes More articles by this author Peter Kirk More articles by this author Tudor Borza More articles by this author Yongmei Qin More articles by this author Ted Skolarus More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

OBJECTIVE To investigate the influences of inflammatory bowel disease (IBD), a rare but morbid disease with increasing incidence, on prostate cancer management decisions. We examined whether prostate cancer treatment differed for men with IBD, and whether treatment choice was associated with risk of IBD flare.MATERIALS AND METHODS Using Veterans Health Administration cancer registry and administrative data, we identified 52,311 men diagnosed with prostate cancer from 2005 to 2008. We used International Classification of Diseases-9 codes and pharmacy and utilization data to identify IBD diagnoses, IBD-directed therapy, and flares (glucocorticoid escalation, hospitalization, and surgical intervention). We compared characteristics across men with and without IBD, and used multivariable regression to examine IBD flares after treatment according to treatment type.RESULTS Two hundred and forty men (0.5%) had IBD prior to prostate cancer diagnosis. Compared to non-IBD patients, IBD patients were more likely Caucasian (P <.001) with lower-risk cancer (P =.02). Surgery was more common in IBD patients (41% vs 28%, P <.001). In the year following prostate cancer treatment, 18% of IBD patients experienced flares. After adjustment, the only predictor of flare in the year after treatment was flare in the year prior to treatment (adjusted odds ratio, 12.5; 95% confidence interval, 5.4-29.2).CONCLUSION IBD patients were more likely to have lower-risk disease and be treated with surgery. Choice of prostate cancer treatment did not predict flares in the subsequent year. Better understanding of the intersection of IBD and prostate cancer can help inform treatment decisions for the increasing number of men managing both diseases. Published by Elsevier Inc.