Grace Lu-Yao

Patient-re ported complications and follow-up treatment after radical prostatectomy

To estimate the probabilities of complications and follow-up treatment, a sample of Medicare patients who underwent radical prostatectomy (1988 through 1990) was surveyed by mail, telephone, and personal interview. Respondents reported their current status with respect to continence and sexual function as well as post-surgical treatments they had had to treat residual or recurrent cancer or surgical complications. Over 30 percent reported currently wearing pads or clamps to deal with wetness; over 40 percent said they drip urine when they cough or when their bladders are full; 23 percent reported daily wetting of more than a few drops. About 60 percent of patients reported having no full or partial erections since their surgery, and only 11 percent had any erections sufficient for intercourse during the month prior to the survey. Six percent had surgery after the radical prostatectomy to treat incontinence; 15 percent had treatments or used devices to help with sexual function; 20 percent report having had post-surgical treatment for urethral strictures. In addition 16 percent, 22 percent, and 28 percent reported follow-up treatment for cancer (radiation or androgen deprivation therapy) at two, three, and four years after radical prostatectomy. These estimates of complication and follow-up treatment rates are generally higher, and almost certainly more representative for older men, than estimates previously published. Patients and physicians may want to weight heavily the complications and need for follow-up treatments when considering radical prostatectomy for prostate cancer.

Outcomes after displaced fractures of the femoral neck. A meta-analysis of one hundred and six published reports.

Methods of meta-analysis, a technique for the combination of data from multiple sources, were applied to analyze 106 reports of the treatment of displaced fractures of the femoral neck. Two years or less after primary internal fixation of a displaced fracture of the femoral neck, a non-union had developed in 33 per cent of the patients and avascular necrosis, in 16 per cent. The rate of performance of a second operation within two years ranged from 20 to 36 per cent after internal fixation and from 6 to 18 per cent after hemiarthroplasty (relative risk, 2.6; 95 per cent confidence interval, 1.4 to 4.6). Conversion to an arthroplasty was the most common reoperation after internal fixation and accounted for about two-thirds of these procedures. The remaining one-third of the reoperations were for removal of the implant or revision of the internal fixation. For the patients who had had a hemiarthroplasty, the most common reoperations were conversion to a total hip replacement, removal or revision of the prosthesis, and debridement of the wound. Although we observed an increase in the rate of mortality at thirty days after primary hemiarthroplasty compared with that after primary internal fixation, the difference was not significant (p = 0.22) and did not persist beyond three months. The absolute difference in perioperative mortality between the two groups was small. An anterior operative approach for arthroplasty consistently was associated with a lower rate of mortality at two months than was a posterior approach. Some reports showed promising results after total hip replacement for displaced fractures of the femoral neck; however, randomized clinical trials are still needed to establish the value of this treatment.

Effect of radical prostatectomy for prostate cancer on patient quality of life: results from a medicare survey

OBJECTIVESnTo assess patient responses to radical prostatectomy and its effects.nnnMETHODSnA national sample was taken of 1072 Medicare patients who underwent radical prostatectomy for prostate cancer (1988 through 1990) by mail, telephone, and personal interviews. The effects of the surgery and its complications on these patients lives were studied through: (1) patient ratings of the extent to which sexual and urinary dysfunctions were problems in their lives; (2) two general measures of quality of life, the Mental Health Index and the General Health Index; (3) patient reports of how they felt about the results of treatment and whether they would choose surgery again.nnnRESULTSnOn average, dripping urine, particularly to the point where subjects were wearing pads, had a more significant effect on patients than loss of sexual function; incontinence had significant adverse effects on the measures of quality of life and self-reported results of surgery. Overall, postsurgical patients scored comparatively high on the quality of life measures (similar to a cohort of patients with benigh prostatic hyperplasia who had undergone transurethral resection of the prostate), reported feeling positive about the results (81%), and would choose surgical treatment again (89%). Nonetheless, there was variability in patient response to the effects of surgery.nnnCONCLUSIONSnThe results demonstrate the ability of many Medicare patients to adapt to adverse outcomes, such as loss of sexual function and incontinence. They also provide evidence of the variability of individual patients responses to surgical results and reinforce the importance of individualized decision making for patients facing a decision about radical prostatectomy for prostate cancer.

Survival following primary androgen deprivation therapy among men with localized prostate cancer.

CONTEXTnDespite a lack of data, increasing numbers of patients are receiving primary androgen deprivation therapy (PADT) as an alternative to surgery, radiation, or conservative management for the treatment of localized prostate cancer.nnnOBJECTIVEnTo evaluate the association between PADT and survival in elderly men with localized prostate cancer.nnnDESIGN, SETTING, AND PATIENTSnA population-based cohort study of 19,271 men aged 66 years or older receiving Medicare who did not receive definitive local therapy for clinical stage T1-T2 prostate cancer. These patients were diagnosed in 1992-2002 within predefined US geographical areas, with follow-up through December 31, 2006, for all-cause mortality and through December 31, 2004, for prostate cancer-specific mortality. Instrumental variable analysis was used to address potential biases associated with unmeasured confounding variables.nnnMAIN OUTCOME MEASURESnProstate cancer-specific survival and overall survival.nnnRESULTSnAmong patients with localized prostate cancer (median age, 77 years), 7867 (41%) received PADT, and 11,404 were treated with conservative management, not including PADT. During the follow-up period, there were 1560 prostate cancer deaths and 11,045 deaths from all causes. Primary androgen deprivation therapy was associated with lower 10-year prostate cancer-specific survival (80.1% vs 82.6%; hazard ratio [HR], 1.17; 95% confidence interval [CI], 1.03-1.33) and no increase in 10-year overall survival (30.2% vs 30.3%; HR, 1.00; 95% CI, 0.96-1.05) compared with conservative management. However, in a prespecified subset analysis, PADT use in men with poorly differentiated cancer was associated with improved prostate cancer-specific survival (59.8% vs 54.3%; HR, 0.84; 95% CI, 0.70-1.00; P = .049) but not overall survival (17.3% vs 15.3%; HR, 0.92; 95% CI, 0.84-1.01).nnnCONCLUSIONnPrimary androgen deprivation therapy is not associated with improved survival among the majority of elderly men with localized prostate cancer when compared with conservative management.

Outcomes of external-beam radiation therapy for prostate cancer: a study of Medicare beneficiaries in three surveillance, epidemiology, and end results areas.

PURPOSEnThis study was designed to obtain representative estimates of the quality of life and probabilities of possible adverse effects among Medicare-age patients treated with external-beam radiation therapy for prostate cancer.nnnMETHODSnPatients treated for local or regional prostate cancer with high-energy external-beam radiation between 1989 and 1991 were sampled from a claims data base of the Surveillance, Epidemiology, and End Results (SEER) program from three regions. Patients were surveyed primarily by mail, with telephone follow-up evaluation of non-respondents. There were 621 respondents (83% response rate). The results were compared with data from a previously published national survey of Medicare-age men who had undergone radical prostatectomy.nnnRESULTSnAlthough they were older at the time of treatment, radiation patients were less likely than surgical patients to wear pads for wetness (7% v 32%) and had a lower rate of impotence (23% v 56% for men < 70 years), while they were more likely to report problems with bowel dysfunction (10% v 4%). Both groups reported generally positive feelings about their treatments. Radiation and surgical patients reported similar rates of additional subsequent treatment (24% v 26% at 3 years after primary treatment). However, radiation patients were less likely to say they were cancer-free, and they reported more worry about cancer than did surgical patients.nnnCONCLUSIONnThe health-related quality of life of radiation and surgical patients, on average, is similar, but the pattern of experience with adverse consequences of treatment differs by treatment.

Treatment and survival among elderly Americans with hip fractures: a population-based study.

OBJECTIVESnThis study was undertaken to examine the patterns of treatment and survival among elderly Americans with hip fracture.nnnMETHODSnA 5% national sample of Medicare claims was used to identify patients who sustained hip fractures between 1986 and 1989. In comparing treatment patterns across regions, direct standardization was used to derive age- and race-adjusted percentages. Logistic regression and Cox regression were used to examine short- and long-term survival.nnnRESULTSnIn the United States, 64% of femoral neck fractures were treated with arthroplasty; 90% of pertrochanteric fractures were treated with internal fixation. Higher short- and long-term mortality was associated with being male, being older, residing in a nursing home prior to fracture, having a higher comorbidity score, and having a pertrochanteric fracture. Blacks and Whites had similar 90-day postfracture mortality, but Blacks had a higher mortality later on. For femoral neck fracture, internal fixation has a modestly lower short-term mortality associated with it than arthroplasty has.nnnCONCLUSIONnVariation in the treatment of hip fracture was modest, The increased delayed mortality after hip fracture among Blacks requires further study.

Transurethral resection of the prostateamong medicare beneficiaries in the United States: time trends and outcomes

Abstract Objectives. The purpose of this study was to examine the epidemiology of transurethral resection of the prostate (TURP) and associated risks among Medicare beneficiaries during the period of 1984 to 1990. Methods. Medicare hospital claims for a 20% national sample of Medicare beneficiarieswere used to identify TURPS performed during the study period. All reported rates were adjusted to the composition of the 1990 Medicare population. Risks of mortality and reoperation were evaluated using life-table methods. Results. The age-adjusted rate of TURP reached a peak in 1987 and declined thereafter. Similar trends were observed for all age groups. In 1990, the rates of TURP (including all indications) were approximately 25, 19, and 13 per 1000 for men over the age of 75, 70 to 74, and 65 to 69, respectively. The 30-day mortality following TURP for the treatment of benign prostatic hyperplasia (BPH) decreased from 1.20% in 1984 to 0.77% in 1990 (linear trend, p = 0.0001). The cumulative incidence of a second TURP among men with BPH has likewise decreased steadily over time; in this study, the average was 7.2% over 7 years (5.5% when the indication for the second TURP was restricted to BPH only). Conclusions. The rate of TURP has been declining since 1987, conceivably due to increasing availability of alternative treatments or changes in treatment preferences of patients and physicians. Over the same period, the outcomes following TURPS have improved, perhaps due to improved surgical care and changes in patient selection.

Effect of age and surgical approach on complications and short-term mortality after radical prostatectomy--a population-based study.

OBJECTIVESnTo use population-based data to accurately delineate the types and incidence of complications, risk of readmission, and influence of age and surgical approach on short-term mortality after radical prostatectomy.nnnMETHODSnMedicare claims from 1991 to 1994 were used to identify and quantify the types and risks of complications, rehospitalization within 90 days, and mortality at 30 and 90 days after perineal or retropubic prostatectomy. Logistic regression was used to determine the relationships between age, surgical approach, and short-term outcomes while adjusting for potential confounders.nnnRESULTSnOn the basis of data from 101,604 men, complications affected 25.0% to 28.8% of patients treated with the perineal or retropubic approach. The retropubic approach had a higher risk of respiratory complications (relative risk [RR] = 1.53, 95% confidence interval [CI] 1.37 to 1.71) and miscellaneous medical complications (RR = 1.77, 95% CI 1.60 to 1.97) and a lower risk of miscellaneous surgical complications (RR = 0.86, 95% CI 0.78 to 0.94). Differences in medically related gastrointestinal complications partially accounted for the differences in miscellaneous medical complications. Rectal injury with the perineal approach was only approximately 1% to 2%. Readmission within 90 days was necessary for 8.5% to 8.7% of patients who underwent the retropubic or perineal approach. The 30-day mortality was less than 0.5% for men aged 65 to 69; it approached 1% for men aged 75 and older.nnnCONCLUSIONSnComplications and readmission after prostatectomy are substantially more common than previously recognized. Notable differences exist in the incidence of respiratory and nonsurgical gastrointestinal complications, although many short-term outcomes are comparable for the two approaches. Older age is associated with elevated surgical mortality and complications.

Transurethral resection of the prostate among medicare beneficiaries : 1984 to 1997

Purpose: We examine the epidemiology and associated risks of transurethral resection of the prostate among Medicare beneficiaries for the period 1984 to 1997.Materials and Methods: We used hospital claims for transurethral resection of the prostate from a 20% national sample of Medicare beneficiaries for the period 1991 to 1997. Risk of mortality and reoperation were evaluated using life table methods and compared to those for the period 1984 to 1990. We also examined the association between surgical volume and adverse outcomes following resection using unique urologist identifier codes from the 1997 part B Medicare claims.Results: Compared to 1984 to 1990, age adjusted rates of transurethral resection for benign prostatic hyperplasia (BPH) during 1991 to 1997 declined by approximately 50% for white (14.6 to 6.72/1,000) and 40% for black (11.8 to 6.58/1,000) men. Of the men who underwent resection for BPH during the recent period 53% were 75 years old or older but 30-day mortality in men 70 years old or o...

Treatments for prostate cancer in older men: 1984–1997

OBJECTIVESnTo examine the temporal trends in radical prostatectomy (RP), brachytherapy (BT), and external beam radiotherapy (EBRT) rates among men aged 65 years or older for the period 1984 to 1997.nnnMETHODSnWe used the retrospective population-based analysis of treatments for prostate cancer among Medicare beneficiaries. The rates of RP were obtained from Part A (hospital) Medicare data for 20% of the national sample for 1984 to 1997. The BT and EBRT rates for the period 1993 to 1997 were obtained from a 5% national sample of Physician/Supplier Part B data. The rates of treatment, 30-day mortality, and readmissions were included.nnnRESULTSnThe rate of RP peaked in 1992. From 1993 to 1997, its use decreased by 6% among men aged 65 to 69 years, 34% among men aged 70 to 74 years, and 50% for men aged 75 years or older. However, by 1997, the RP + BT treatment rate again approached the 1992 levels of RP alone; BT was used twice as often as RP in men aged 75 years or older. By 1997, the RP + BT + EBRT rate exceeded the 1993 rate for men aged 65 to 69 years and was again approaching the 1993 rate for men aged 70 to 74 years. From 1984 to 1997, the presence of comorbid conditions gradually declined for RP and accounted for more than 60% of the decrease in the short term mortality during this period. Variations in RP use by geographic region have also decreased.nnnCONCLUSIONSnRP is now more selectively targeted for treatment of prostate cancer in men older than 70 years than in the past. However, since BT has been substituted for radical surgery in many of these older men, the total population-based treatment rates have changed very little over time.