Joseph Shirk

Patient experience and quality of urologic cancer surgery in US hospitals.

Care interactions as perceived by patients and families are increasingly viewed as both an indicator and lever for high‐value care. To promote patient‐centeredness and motivate quality improvement, payers have begun tying reimbursement with related measures of patient experience. Accordingly, the authors sought to determine whether such data correlate with outcomes among patients undergoing surgery for genitourinary cancer.

From QOL to QALYs: Comparing nononcologic outcomes in prostate cancer survivors across treatments ☆

OBJECTIVE We aim to highlight the progression from the early definition of nononcologic outcomes in prostate cancer (PC) to measurement and use of preferences to ensure appropriate treatment decisions in men with localized disease. METHODS We review the assessment of nononcologic outcomes after PC treatment and ways to use the outcomes to augment patient care. RESULTS PC treatments may have similar oncologic efficacy in men with certain clinical features, but they differ in their nononcologic outcomes. Tools to assess these outcomes have been developed and are useful in areas from treatment reimbursement to shared decision-making. CONCLUSIONS The ability to measure and make useful data on nononcologic outcomes evolved substantially over the past 20 years. Current work suggests that individual preference assessment for nononcologic outcomes is a promising means of matching patients with appropriate treatment.

Patient Function and the Value of Surgical Care for Kidney Cancer.

Purpose: Frailty and functional status have emerged as significant predictors of morbidity and mortality for patients undergoing cancer surgery. To articulate the impact on value (ie quality per cost), we compared perioperative outcomes and expenditures according to patient function for older adults undergoing kidney cancer surgery. Materials and Methods: Using linked SEER (Surveillance, Epidemiology and End Results)‐Medicare data, we identified 19,129 elderly patients with kidney cancer treated with nonablative surgery from 2000 to 2009. We quantified patient function using function related indicators (claims indicative of dysfunction and disability) and measured 30‐day morbidity, mortality, resource use and cost. Using multivariable, mixed effects models to adjust for patient and hospital characteristics, we estimated the relationship of patient functionality with both treatment outcomes and expenditures. Results: Of 19,129 patients we identified 5,509 (28.8%) and 3,127 (16.4%) with a function related indicator count of 1 and 2 or greater, respectively. While surgical complications did not vary (OR 0.95, 95% CI 0.86–1.05), patients with 2 or more indicators more often experienced a medical event (OR 1.22, 95% CI 1.10–1.36) or a geriatric event (OR 1.55, 95% CI 1.33–1.81), or died within 30 days of surgery (OR 1.43, 95% CI 1.10–1.86) compared with patients with no baseline dysfunction. These patients utilized significantly more medical resources and amassed higher acute care expenditures (p <0.001). Conclusions: During kidney cancer surgery, patients in poor functional health can face a more eventful medical recovery at elevated cost, indicating lower value care. Greater consideration of frailty and functional status during treatment planning and transitions may represent areas for value enhancement in kidney cancer and urology care.

Health Insurance Status and Disparities in Kidney Cancer Care

Introduction: Through PPACA (Patient Protection and Affordable Care Act) many adults have or will gain health insurance via Medicaid expansion. To understand how this policy change may potentially impact patients with kidney cancer we examined the relationship between insurance status and cancer related outcomes. Methods: Using SEER (Surveillance, Epidemiology and End Results) data we identified 18,632 patients 26 to 64 years old with kidney cancer from 2007 to 2009. For each patient we classified insurance status as no insurance, Medicaid or private insurance. After adjusting for patient and county characteristics we measured the association of insurance status with cancer stage, treatment and 1‐year mortality using multinomial logistic regression with clustering or generalized estimating equations as appropriate. Results: In our study cohort 937 (5.0%) and 2,027 patients (10.9%) had no insurance and Medicaid, respectively. These patients were more likely to be younger, nonwhite, unmarried and residing in areas with lower income, education or employment (p <0.001). On adjusted analyses uninsured and Medicaid patients more often presented with advanced disease (21.3% vs 19.6% vs 11.0%) but less frequently received treatment (86.2% vs 87.9% vs 93.4%, each p <0.001) compared with privately insured patients. These adults also died of kidney cancer more often (13.6% vs 12.5% vs 6.4%, p <0.001) likely due to differences in stage and receipt of cancer directed therapy. Conclusions: Uninsured and Medicaid patients suffer disproportionately from kidney cancer with equal magnitude. Given the reliance on Medicaid, even as insurance coverage expands differences in outcomes will likely persist, underscoring the need for additional efforts that address disparities in kidney cancer care.

Decisional Quality in Patients With Small Renal Masses

OBJECTIVE To measure decisional quality in patients being counseled on treatment for small renal masses and identify potential areas of improvement. MATERIALS AND METHODS A total of 73 patients diagnosed with small renal masses at the University of California, Los Angeles Health completed an instrument measuring decisional conflict, patient satisfaction with care, disease-specific knowledge, and patient impression that shared decision-making occurred in the visit after counseling by a specialist. Participant characteristics were compared between those with high and low decisional conflict using chi-square or Student t test (or Wilcoxon rank-sum test). RESULTS Participants were mostly older (mean age 63.5), white (84%), in a relationship (61%), and unemployed or retired (63%). Mean knowledge score was 59% correct. The mean (standard deviation) decisional conflict score was 16.4 (18.4) indicating low levels of decisional conflict but with a wide range of scores. Comparing participants with high decisional conflict with those with low decisional conflict, there were significant differences in knowledge scores (Wilcoxon P = .0069), patient satisfaction with care (P = .0011), and perceived shared decision-making (P <.0001). CONCLUSION Patients with small renal masses generally have low levels of decisional conflict and can identify a preferred treatment after a physician visit. However, both groups lack overall knowledge about their disease even after counseling, and thus may be heavily influenced by paternalistic care. Those patients with decisional conflicts are less likely to perceive their care as satisfactory and are less likely to be involved in decision-making.

Is More Really Better? An Examination of Services and Payment Patterns among Urologists from the Centers for Medicare & Medicaid Services

Introduction: We examined provider and regional variation in services provided and payments made to urologists by CMS (Centers for Medicare & Medicaid Services) by linking payments to individual beneficiaries and examining the proportion of submitted charges resulting in payments. Methods: We analyzed Medicare Part B Provider Utilization and Payment Data released by CMS for 2012, the last year of the purely fee‐for‐service reimbursement model. For each provider we determined the ratio of number of services provided to individual beneficiaries as well as the ratio of total submitted charges‐to‐total Medicare payments. Each provider was stratified into deciles of total Medicare payments and the mean per decile of total Medicare payment was calculated. Finally, to elucidate the potential association between the ratio of services‐to‐beneficiaries, we conducted multivariate linear regressions. Results: The 20th, 40th, 60th and 80th percentiles for the ratio of number of services per individual beneficiary ratios to total Medicare Part B payments are 2.8, 4.0, 5.2 and 7.4, respectively. Urologists with greater payments received provided more services to individual beneficiaries. Submitted charges exceeded payments by 3:1. Finally, female providers had lower ratios (p <0.01) and there was significant regional variation in the ratio of services per unique beneficiary (p <0.001 for each of the 10 Standard Federal Regions). Conclusions: We found significant variation in services and payment in CMS. Reimbursement models replacing fee‐for‐service should be tailored to ensure appropriate health care resource utilization.

PD06-02 DECISIONAL QUALITY AND THE IMPACT OF SHARED DECISION MAKING AMONG PATIENTS WITH UROLOGIC STONE DISEASE

INTRODUCTION AND OBJECTIVES: To assess the contemporary knowledge of Human Papillomavirus (HPV) and its association with penile cancer in a nationwide cohort from the US. METHODS: We utilized the Health Information National Trends Survey (HINTS), a cross-sectional telephone survey performed in the US initiated by the National Cancer Institute. Themost recent iteration, HINTS 4Cycle4,wasconducted inmail formatbetweenAugust 19andNovember 17, 2014. Primary endpoints included knowledge of HPV and its causal relationship to penile cancer. Baseline characteristics included sex, age, education, race&ethnicity, income, residency, personal or family history of cancer, health insurance status, and internet use. Multivariable logistic regression assessed predictors of HPV and penile cancer knowledge. RESULTS: An unweighted sample of 3,376 respondents was extracted from the HINTS 4, Cycle 4. Whereas 64.4% of respondents had heard of HPV, only 29.5% of these were aware that it could cause penile cancer. Men were significantly less likely to have heard of HPV than women (OR 0.32 95% CI 0.24-0.43). Older age; African-American, Asian, and “other race”; being married; from a lower education bracket; having a personal cancer history; and those without internet access were significantly less likely to have heard of HPV. None of our examined variables were independent predictors for the knowledge of the association of penile cancer and HPV. CONCLUSIONS: Our analysis of a large, nationally representative survey demonstrates that the majority of the American public is familiar with HPV but lack a meaningful understanding between this virus and penile cancer. Primary care providers and specialists should be encouraged to intensify counseling about this significant association as a primary preventive measure of this potentially fatal disease.

PD09-07 THE IMPACT OF SHARED DECISION MAKING SOFTWARE ON DECISIONAL QUALITY OF MEN UNDERGOING TREATMENT FOR BPH: AN INTERIM ANALYSIS

INTRODUCTION AND OBJECTIVES: Physicians need practical methods to accurately estimate life expectancy when counseling older men with comorbidities regarding treatment of prostate cancer. Although numerous nomograms exist for prediction of life expectancy (LE), few are used in practice due to the difficulty of integration into busy clinical workflows. We sought to determine if survival could be accurately predicted if reduced to a count of several common comorbidities that pose a high risk to mortality. In selecting these comorbidities, we aimed to balance frequency and risk in order to maximize identification of men at risk for overtreatment based on <10-year LE. METHODS: We sampled 1,598 men with newly diagnosed prostate cancer at two Southern California Veterans Affairs Medical Centers from 1998 to 2004. We created rank-ordered lists of comorbidities organized by frequency and highest risk of mortality. Separate ranked lists were then created by differentially weighting comorbidities by frequency to risk ratios: 1:6, 1:4, 1:2, 1:1, 2:1, 4:1, and 6:1. By successively adding comorbidities from highestto tenth highestranked, a set of 10 candidate comorbidity indices was constructed for each list. Using competing risks regression analysis, we determined cindex, the number of men with <10-year LE, and the number of men with <10-year LE treated with surgery or radiation for each index. RESULTS: Candidate comorbidity indices heavily weighted by frequency were poor at identifying men with <10-year LE, while indices heavily weighted by risk of mortality failed to identify men who were overtreated. Six candidate indices each found more than 300 men with <10-year LE (range 303-392); all six were weighted either 2:1, 1:1, or 1:2 by frequency to risk ratio and included highly similar comorbidities. Two of the six indices identified more than 200 men with <10-year LE overtreated with surgery or radiation (range 173-203). The candidate index with the highest number overtreated was weighted 1:1 by frequency to risk and included six comorbidities: 1) chronic obstructive pulmonary disease 2) congestive heart failure 3) peripheral vascular disease 4) stroke 5) myocardial infarction 6) exertional angina. C-index for this index was 0.66. CONCLUSIONS: A simple count of six comorbidities predicts the risk of 10-year other-cause mortality and robustly identifies men who are overtreated for early stage prostate cancer. Simplifying estimation of life expectancy may be key to operationalizing this critical variable for prostate cancer decision-making.

MP86-14 PROSTATE SPECIFIC ANTIGEN AND HEALTH-RELATED QUALITY-OF-LIFE OUTCOMES IN UNINSURED MEN WITH PROSTATE CANCER

INTRODUCTION AND OBJECTIVES: Interest in disease-specific psychological well-being of patients with cancer has increased, and it has been estimated that less than half of all cancer patients are properly identified and treated for anxiety or depression. The aim of this study was to evaluate psychological health assessment in oncological patients admitted for surgery. METHODS: We performed a cross-sectional study in consecutively enrolled patients with bladder, kidney or prostate cancer, scheduled for surgery. Demographic data, socioeconomic status, education level and diagnoses were recorded. We evaluated the level of clinically meaningful depression and anxiety assessed by two tools: the Hospital Anxiety and Depression Scale and the State-Trait Anxiety Inventory (STAI). In order to determine variables related to depression and anxiety among the demographic variables, logistic regression analyses were conducted, with p<0.05 considered as statistically significant. RESULTS: 207 patients completed the questionnaires and were included in the study. The most frequent procedures were performed for bladder tumours (60.4%), being transurethral resection the most common type of surgery (52.7%) followed by radical prostatectomy (24.6%). The mean STAI-state score was 19.3 ( 10.3), and the mean STAI-trait score was 18.4 ( 11.9) points. Patients showed HADs depression and anxiety scores of 3.3 ( 3) and 5.6 ( 3.3) points, respectively. Female patients showed a higher level of anxiety and STAI-trait compared to males. CONCLUSIONS: Gender, tumour type and surgical approach were significantly related to psychological distress in patients undergoing surgery for urological cancer. Females and patients with kidney tumour undergoing radical nephrectomy presented higher levels of anxiety.

MP31-09 COMORBIDITY, DISABILITY, AND PARTIAL NEPHRECTOMY USE FOR OLDER PATIENTS WITH STAGE I KIDNEY CANCER

INTRODUCTION AND OBJECTIVES: To evaluate the association between frailty and post-operative discharge destination after different types of commonly performed urologic procedures of varying complexity in older patients. METHODS: Using data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) from 2011 to 2013, we identified commonly performed urologic procedures among patients age 65 and older. We then assessed the impact of frailty, measured by the NSQIP Frailty Index (NSQIP-FI), on discharge to a skilled or assisted living facility using logistic regression. We then assessed the heterogeneity of this effect across procedures using twolevel random effects modeling. RESULTS: Among the 37,657 patients who under went 1 of 20 different commonly performed urologic procedures, 1,171 (3.1%) were discharged to a skilled or assisted living facility during the study period. Discharge to a facility was most common after cystectomy (16%). Overall, 2.1% of patients ages 80 and older undergoing urologic surgery were discharged to a facility, while 5.8% of older individuals undergoing urologic surgery who were frail (NSQIP FI1⁄40.18+), 15.4% of smokers and 15.6% of patients undergoing non-elective surgery were discharged to such facilities. Frailty was strongly associated with discharge to a facility [adjusted OR 3.10 (96% CI 2.60, 3.80) for NSQIP-FI 0.18+ compared to NSQIP FI 0]. Additional predictors included increasing age, smoking and recent weight loss. Race, other than white or black, anesthesia techniques other than general, and elective surgery were all associated with a lower risk of discharge to a facility. This finding was consistent across procedures of varying complexity with an overall effect of log OR 0.61 (95% CI 0.46, 0.76) using two-level random effects modeling (figure). CONCLUSIONS: Increasing frailty is associated with discharge to a skilled or assisted living facility across nearly all urologic procedures evaluated, regardless of complexity. This information is important for preoperative counseling with patients undergoing urologic surgery.