Andrew Brachulis

Measuring to Improve: Peer and Crowd-sourced Assessments of Technical Skill with Robot-assisted Radical Prostatectomy

UNLABELLED Because surgical skill may be a key determinant of patient outcomes, there is growing interest in skill assessment. In the Michigan Urological Surgery Improvement Collaborative (MUSIC), we assessed whether peer and crowd-sourced (ie, layperson) video review of robot-assisted radical prostatectomy (RARP) could distinguish technical skill among practicing surgeons. A total of 76 video clips from 12 MUSIC surgeons consisted of one of four parts of RARP and underwent blinded review by MUSIC peer surgeons and prequalified crowd-sourced reviewers. Videos were rated for global skill (Global Evaluation Assessment of Robotic Skills) and procedure-specific skill (Robotic Anastomosis and Competency Evaluation). We fit linear mixed-effects models to estimate mean peer and crowd ratings for each video. Individual video ratings were aggregated to calculate surgeon skill scores. Peers (n=25) completed 351 video ratings over 15 d, whereas crowd-sourced reviewers (n=680) completed 2990 video ratings in 38 h. Surgeon global skill scores ranged from 15.8 to 21.7 (peer) and from 19.2 to 20.9 (crowd). Peer and crowd ratings demonstrated strong correlation for both global (r=0.78) and anastomosis (r=0.74) skills. The two groups consistently agreed on the rank order of lower scoring surgeons, suggesting a potential role for crowd-sourced methodology in the assessment of surgical performance. Lack of patient outcomes is a limitation and forms the basis of future study. PATIENT SUMMARY We demonstrated the large-scale feasibility of assessing the technical skill of robotic surgeons and found that online crowd-sourced reviewers agreed with experts on the rank order of surgeons with the lowest technical skill scores.

A Statewide Intervention Improves Appropriate Imaging in Localized Prostate Cancer

Purpose: We implemented a statewide intervention to improve imaging utilization for the staging of patients with newly diagnosed prostate cancer. Materials and Methods: MUSIC (Michigan Urological Surgery Improvement Collaborative) is a quality improvement collaborative comprising 42 diverse practices representing approximately 85% of the urologists in Michigan. MUSIC has developed imaging appropriateness criteria (prostate specific antigen greater than 20 ng/ml, Gleason score 7 or higher and clinical stage T3 or higher) which minimize unnecessary imaging with bone scan and computerized tomography. After baseline rates of radiographic staging were established in 2012 and 2013, we used multidimensional interventions to deploy these criteria in 2014. Imaging utilization was then remeasured in 2015 to evaluate for changes in practice patterns. Results: A total of 10,554 newly diagnosed patients with prostate cancer were entered into the MUSIC registry from January 1, 2012 through December 31, 2013 and January 1, 2015 through December 31, 2015. Of these patients 7,442 (79%) and 7,312 (78%) met our criteria to avoid bone scan and computerized tomography imaging, respectively. The use of bone scan imaging when not indicated decreased from 11.0% at baseline to 6.5% after interventions (p <0.0001). The use of computerized tomography when not indicated decreased from 14.7% at baseline to 7.7% after interventions (p <0.0001). Variability among practices decreased substantially after the interventions as well. The use of recommended imaging remained stable during these periods. Conclusions: An intervention aimed at appropriate use of imaging was associated with decreased use of bone scans and computerized tomography among men at low risk for metastases.

A Roadmap for Improving the Management of Favorable Risk Prostate Cancer

A proposed solution to concerns about overpriorities. MUSIC is a consortium of more than 250 treatment of men with favorable risk, early stage prostate cancer is the unlinking of diagnosis from treatment through expanded use of active surveillance and selective delayed intervention. At a population level the safety and impact of surveillance as a strategy for reducing overtreatment depend on accurate initial identification of men with indolent tumors, followed by periodic monitoring for changes in either cancer severity or patient preferences which may prompt transition to definitive therapy while the cancer is still curable. Although recent reports indicate that a growing proportion of men with favorable risk prostate cancer are undergoing surveillance, rates of adoption in the United States often lag behind those reported internationally, and challenges to safe and successful implementation across large populations remain. The documented wide variation in adoption across physicians may indicate residual uncertainty regarding patient selection for surveillance. Furthermore, many men are entering surveillance after a single diagnostic biopsy and without an early reassessment aimed at confirming tumor severity (eg repeat biopsy or other testing). Finally, the surveillance process is predicated on adherence to a regular cadence of repeat clinical evaluations, prostate specific antigen (PSA) blood tests and prostate biopsy but, in reality, many men receive less frequent followup than recommended by current guidelines. This less active surveillance is concerning in light of recent data indicating that men infrequently monitored have an increased risk of cancer progression relative to those receiving definitive treatment with surgery or radiation. Accordingly, coordinated efforts aimed at refining patient selection, expanding the use of confirmatory tests of cancer severity and ensuring reliable followup are essential to increase the safety, sustainability and ultimate impact of surveillance as a strategy for reducing overtreatment. MUSIC (Michigan Urological Surgery Improvement Collaborative) is pursuing each of these

Evaluation of a needle disinfectant technique to reduce infection-related hospitalisation after transrectal prostate biopsy

To determine whether a needle disinfectant step during transrectal ultrasonography (TRUS)‐guided prostate biopsy is associated with lower rates of infection‐related hospitalisation.

PD58-07 MUSIC OCTAVE – COMPOSITE MEASURES TO ASSESS SURGEON PERFORMANCE FOR ROBOTIC PROSTATECTOMY

evaluated the type and quantity of opioids prescribed, standardized to morphine milligram equivalents (MME). Finally, we quantified surgeonspecific variation in MMEs prescribed for surgeons with 10 or more patients in the cohort, and at least 5 filling an opioid prescription postoperatively. RESULTS: We identified 25,102 men who received a vasectomy during the study interval. Among this group, 10,442 (41.6%) patients filled an opioid prescription after surgery. Hydrocodone was the most common medication, comprising 66.7% of filled prescriptions. The median number of MMEs prescribed was 112.5 [IQR 82.5-150]; equivalent to twenty-three, 5 mg hydrocodone tablets per prescription [IQR 16.5-30 tablets/ prescription]. Across 360 surgeons meeting criteria for surgeon-specific analysis, the average number of MMEs prescribed after vasectomy varied substantially (range: 29.2-390 MMEs (p<0.001); corresponding to a range of six to seventy-eight, 5 mg hydrocodone tablets per prescription (Figure). CONCLUSIONS: Less than half of men fill an opioid prescription following vasectomy, indicating that non-opioid pain strategies may be sufficient for most patients. Nonetheless, surgeon-specific analyses revealed a 13-fold difference in the average quantity of opioids supplied. Because patient necessity is unlikely to entirely explain this variability, efforts to reduce excess opioid prescribing after vasectomy are warranted.

PD58-06 SURGICAL SKILL AND PATIENT OUTCOMES AFTER ROBOT-ASSISTED RADICAL PROSTATECTOMY

evaluated the type and quantity of opioids prescribed, standardized to morphine milligram equivalents (MME). Finally, we quantified surgeonspecific variation in MMEs prescribed for surgeons with 10 or more patients in the cohort, and at least 5 filling an opioid prescription postoperatively. RESULTS: We identified 25,102 men who received a vasectomy during the study interval. Among this group, 10,442 (41.6%) patients filled an opioid prescription after surgery. Hydrocodone was the most common medication, comprising 66.7% of filled prescriptions. The median number of MMEs prescribed was 112.5 [IQR 82.5-150]; equivalent to twenty-three, 5 mg hydrocodone tablets per prescription [IQR 16.5-30 tablets/ prescription]. Across 360 surgeons meeting criteria for surgeon-specific analysis, the average number of MMEs prescribed after vasectomy varied substantially (range: 29.2-390 MMEs (p<0.001); corresponding to a range of six to seventy-eight, 5 mg hydrocodone tablets per prescription (Figure). CONCLUSIONS: Less than half of men fill an opioid prescription following vasectomy, indicating that non-opioid pain strategies may be sufficient for most patients. Nonetheless, surgeon-specific analyses revealed a 13-fold difference in the average quantity of opioids supplied. Because patient necessity is unlikely to entirely explain this variability, efforts to reduce excess opioid prescribing after vasectomy are warranted.

MP43-02 VARIATION IN USE OF CONFIRMATORY TESTING AMONG ACTIVE SURVEILLANCE CANDIDATES

delays in detecting grade progression (Figure Simulated increase in time to detecting grade progression based on number of biopsies eliminated from annual biopsy routine. Each point represents a unique AS biopsy strategy. Biopsies during a 10 year period would occur as indicated in the legend.) CONCLUSIONS: While annual biopsy for low-risk men on AS is associated with the shortest time to detection of Gleason 7 disease, several alternative strategies may allow for less frequent biopsy without sizable increases in time to detecting grade progression.