Amy N. Luckenbaugh

Safety and Early Oncologic Effectiveness of Primary Robotic Retroperitoneal Lymph Node Dissection for Nonseminomatous Germ Cell Testicular Cancer.

BACKGROUND Primary robot-assisted retroperitoneal lymph node dissection (R-RPLND) has been studied as an alternative to open RPLND in single-institution series for patients with low-stage nonseminomatous germ cell tumors (NSGCT). OBJECTIVE To evaluate a multicenter series of primary R-RPLND for low-stage NSGCT. DESIGN, SETTING, AND PARTICIPANTS Between 2011 and 2015, 47 patients underwent primary R-RPLND at four centers for Clinical Stage (CS) I-IIA NSGCT. SURGICAL PROCEDURE R-RPLND was performed using the da Vinci surgical system (Intuitive Surgical Inc., Sunnyvale, CA, USA). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Data were collected regarding patient demographics, primary tumor characteristics, pathologic findings, and clinical outcomes. RESULTS AND LIMITATIONS Forty-two patients (89%) were CS I and five (11%) were CS IIA. The median operative time was 235min (interquartile range [IQR]: 214-258min), estimated blood loss was 50ml (IQR: 50-100ml), node count was 26 (IQR: 18-32), and length of stay was 1 d. There were two intraoperative complications (4%), four early postoperative complications (9%), no late complications, and the rate of antegrade ejaculation was 100%. Of the eight patients (17%) with positive nodes (seven pN1and one pN2), five (62%) received adjuvant chemotherapy. The one recurrence was out of template in the pelvis after adjuvant chemotherapy (resected teratoma). The median follow-up was 16 mo and the 2-yr recurrence-free survival rate was 97% (95% confidence interval: 82-100%). Limitations include retrospective design and limited follow-up. CONCLUSIONS Our multicenter experience supports R-RPLND as a potential option at experienced centers in select patients with low-stage NSGCT. Informal comparison to open and laparoscopic series suggests R-RPLND has an acceptably low morbidity profile, but oncologic efficacy evaluation requires further evaluation. PATIENT SUMMARY We examined outcomes after robot-assisted retroperitoneal lymph node dissection for patients with low-stage nonseminomatous testicular cancer with our data suggesting the robotic approach has acceptable morbidity and early oncologic outcomes.

Variation in Guideline Concordant Active Surveillance Followup in Diverse Urology Practices

Purpose: We examined the frequency of followup prostate specific antigen testing and prostate biopsy among men treated with active surveillance in the academic and community urology practices comprising MUSIC (Michigan Urological Surgery Improvement Collaborative). Materials and Methods: MUSIC is a consortium of 42 practices that maintains a prospective clinical registry with validated clinical data on all patients diagnosed with prostate cancer at participating sites. We identified all patients in MUSIC practices who entered active surveillance and had at least 2 years of continuous followup. After determining the frequency of repeat prostate specific antigen testing and prostate biopsy, we calculated rates of concordance with NCCN Guidelines® recommendations (ie at least 3 prostate specific antigen tests and 1 surveillance biopsy) collaborative‐wide and across individual practices. Results: We identified 513 patients who entered active surveillance from January 2012 through September 2013 and had at least 2 years of followup. Among the 431 men (84%) who remained on active surveillance for 2 years 132 (30.6%) underwent followup surveillance testing at a frequency that was concordant with NCCN® (National Comprehensive Cancer Network®) recommendations. At the practice level, the median rate of guideline concordant followup was 26.5% (range 10% to 67.5%, p <0.001). Among patients with discordant followup, the absence of followup biopsy was common and not significantly different across practices (median rate 82.0%, p = 0.35). Conclusions: Among diverse community and academic practices in Michigan, there is wide variation in the proportion of men on active surveillance who meet guideline recommendations for followup prostate specific antigen testing and repeat biopsy. These data highlight the need for standardized active surveillance pathways that emphasize the role of repeat surveillance biopsies.

Early effect of Medicare Shared Savings Program accountable care organization participation on prostate cancer care

Accountable care organizations (ACOs) can improve prostate cancer care by decreasing treatment variations (ie, avoidance of treatment in low‐value settings). Herein, the authors performed a study to understand the effect of Medicare Shared Savings Program ACOs on prostate cancer care.

Accountable care organizations and prostate cancer care

Introduction: Accountable care organizations have the potential to increase the value of health care by improving population health and enhancing financial stewardship. How practice context modifies effects on a specialty focused disease, such as prostate cancer care, has implications for their success. Methods: We performed a retrospective cohort study of newly diagnosed men with prostate cancer between 2012 and 2013 using national Medicare data. Practice affiliation (small single specialty, large single specialty, multispecialty groups) and accountable care organization alignment were measured at the patient level. Generalized linear multivariable models were fitted to derive adjusted rates of treatment and spending for the 12‐month period after diagnosis according to accountable care organization alignment and practice affiliation. Results: Of 15,640 patients with newly diagnosed prostate cancer 1,100 (7.0%) were aligned with accountable care organizations. Patients in these organizations had use of curative treatment similar to that of those not in accountable care organizations (71.4% vs 70.0%, respectively, p=0.33), which did not vary with practice affiliation (p=0.39). Adjusted spending was higher among patients in accountable care organizations (

Follow-Up Care after ED Visits for Kidney Stones—A Missed Opportunity

20,916 vs

Emergency Department Switching and Duplicate Computed Tomography Scans in Patients With Kidney Stones

19,773, p=0.03). However, this relationship was independent of practice affiliation (p=0.90). Higher accountable care organization penetration within a practice was associated with increased spending (p <0.05) but not with treatment (p=0.87). Conclusions: Patients with prostate cancer aligned with accountable care organizations had similar rates of treatment but increased spending in the year after diagnosis. These findings were similar across practice affiliations. Better specialist engagement by accountable care organizations may be necessary for them to alter practice patterns for specialty care.

Impact of Accountable Care Organizations on Diagnostic Testing for Prostate Cancer

Introduction: Followup care after an emergency department visit for kidney stones may help reduce emergency department revisits and increase use of stone prevention strategies. To test these hypotheses we analyzed medical claims from working age adults with kidney stones. Methods: Using data from MarketScan® (2003 to 2006) we identified patients with an emergency department visit for kidney stones. We then determined which patients had an outpatient visit within 90 days of emergency department discharge. Finally, we used multivariable logistic regression to evaluate the association between receipt of followup care and emergency department revisit as well as use of stone prevention strategies (24-hour urine testing and preventive pharmacological therapy prescription). Results: Only 48.0% (33,741) of patients seen in the emergency department for kidney stones received followup care, of which 68.3% was with a urologist. While followup care was not associated with fewer emergency department revisits, patients who received it were more likely to undergo 24-hour urine testing (predicted probability 2.2% vs 0.9%, p <0.001) and be prescribed preventive pharmacological therapy (predicted probability 10.6% vs 8.9%, p <0.001) compared to those who did not receive care. Among patients who received followup care, use of stone prevention strategies was higher when the care was delivered by a urologist (predicted probability 13.7% vs 12.3%, p=0.001). Conclusions: More than half of patients seen acutely in the emergency department for kidney stones do not receive followup care. Given that followup care is associated with greater use of stone prevention strategies, efforts to enhance linkages across health care settings are needed to provide higher quality care for patients with urinary stone disease.

Collaborative Quality Initiatives

OBJECTIVE To test whether duplicate imaging relates to a lack of information sharing among providers, we measured the association between emergency department (ED) switching during a kidney stone episode and receipt of a repeat computed tomography (CT) scan. METHODS Using the MarketScan Commercial Claims and Encounters Database, we identified adults between the ages 18 and 64 with an ED visit for a diagnosis of kidney stones. Among patients who had an abdominal or pelvic CT scan at their initial encounter, we then determined the subset that made an ED revisit within 30 days of their first, distinguishing between those to the same vs a different ED. Finally, we fit multivariable logistic regression models to estimate the risk of receiving a repeat CT scan associated with ED switching. RESULTS Twelve percent of patients who received a CT scan at their initial ED encounter had a revisit within 30 days of discharge. One-third of their revisits were made to a different ED than the index one. Duplicate CT scans were obtained at nearly 40% of all revisits. On multivariable analysis, the risk of receiving a repeat CT was 12% higher if this revisit was made to a different ED (risk ratio, 1.12; 95% confidence interval, 1.03-1.21; P = .010). CONCLUSION Our study reveals that ED switching during an acute kidney stone episode is associated with higher levels of repeat CT imaging. These findings support the role of better health information exchange among providers to help reduce waste in the health-care system.

Improving Resident and Nurse Communication Practices: Results of a Collaborative Culture Initiative

OBJECTIVE To determine if Accountable Care Organizations (ACOs) have the potential to accelerate the impact of prostate cancer screening recommendations. METHODS We performed a retrospective cohort study using Medicare data evaluating the rates of PSA testing and prostate biopsy among men without prostate cancer between 2011 and 2014. We assessed PSA testing and biopsy rates before and after policy implementation among patients of ACO and non-ACO-aligned physicians. To control for secular trends, difference-in-differences methods were used to determine the effects of ACO implementation. RESULTS We identified 1.1 million eligible men without prostate cancer. From 2011 to 2014, the rates of PSA testing and biopsy declined by 22.3% and 7.0%, respectively. PSA testing declined similarly regardless of ACO participation-from 618 to 530 tests per 1000 beneficiaries among ACO-aligned physicians and from 607 to 516 tests per 1000 beneficiaries among non-ACO-aligned physicians (difference-in-differences P = .11). Whereas rates of prostate biopsy remained constant for patients of non-ACO-aligned physicians at 12 biopsies per 1000 beneficiaries, these rates increased from 11.6 to 12.5 biopsies per 1000 beneficiaries of patients of ACO-aligned physicians (difference-in-differences P = .03). CONCLUSION PSA testing and prostate biopsy rates decreased significantly between 2011 and 2014. The rate of PSA testing was not differentially affected by ACO participation. Conversely, there was an increase in the rate of prostate biopsy among patients of ACO-aligned physicians. ACOs did not accelerate deimplementation of PSA testing for eligible Medicare beneficiaries without prostate cancer.

Collaborative quality improvement

Quality improvement collaboratives were developed in many medical and surgical disciplines with the goal of measuring and improving the quality of care provided to patients. In urology, there are several such groups, including the Michigan Urological Surgery Improvement Collaborative (MUSIC), the Pennsylvania Urologic Regional Collaborative (PURC) and the International Robotic Cystectomy Consortium (IRCC). In this chapter we will discuss the historic background, rationale and goals of these collaboratives, with a focus on efforts aimed at improving patient selection, intraoperative skills and techniques, and postoperative outcomes following robotic surgery.