Ronald Loo

Stratifying Risk of Urinary Tract Malignant Tumors in Patients With Asymptomatic Microscopic Hematuria

OBJECTIVE To identify patients who could safely avoid unnecessary radiation and instrumentation after the detection of microscopic hematuria. PATIENTS AND METHODS We conducted a prospective cohort study of patients who were referred to urologists and underwent a full evaluation for asymptomatic microscopic hematuria during a 2-year period in an integrated care organization in 3 regions along the West Coast of the United States. A test cohort and validation cohort of patients with hematuria evaluations between January 9, 2009, and August 15, 2011, were identified. Patients were followed passively through their electronic health records for a diagnosis of urothelial or renal cancer. The degree of microscopic hematuria, history of gross hematuria, smoking history, age, race, imaging findings, and cystoscopy findings were evaluated as risk factors for malignant tumors. RESULTS The test cohort consisted of 2630 patients, of whom 55 (2.1%) had a neoplasm detected and 50 (1.9%) had a pathologically confirmed urinary tract cancer. Age of 50 years or older and a recent diagnosis of gross hematuria were the strongest predictors of cancer. Male sex was also predictive of cancer, whereas smoking history and 25 or more red blood cells per high-power field on a recent urinalysis were not statistically significant. A Hematuria Risk Index developed from these factors had an area under the receiver operating characteristic curve of 0.809. In the validation cohort of 1784 patients, the Hematuria Risk Index performed comparably (area under the curve = 0.829). Overall, 32% of the population was identified as low risk and 0.2% had a cancer detected; 14% of the population was identified as high risk, of whom 11.1% had a cancer found. CONCLUSION These results suggest that a considerable proportion of patients could avoid extensive evaluations with the use of the Hematuria Risk Index.

Portal Venous Drainage for Cadaveric Renal Transplantation

The iliac vessels are the standard site for vascular connections for kidney transplantation. Unusual circumstances may render the iliac vessels unusable. We report a case in which a cadaveric renal allograft was successfully transplanted despite an absence of normal venous anatomy, using the inferior mesenteric vein for revascularization.

Trends in Prostate-specific Antigen Screening, Prostate Biopsies, Urology Visits, and Prostate Cancer Treatments From 2000 to 2012.

OBJECTIVE To determine whether the rates of prostate-specific antigen (PSA) screening, related biopsies and subsequent prostate cancer utilization decreased between 2000 and 2012 in a large, managed care organization. METHODS Male members of Kaiser Permanente Southern California who were aged ≥40 years and had no history of prostate cancer (N = 15,326) were passively followed through electronic health plan files from January 1, 2000, through December 31, 2012 (N = 1,539,469). The rates of PSA testing, elevated PSA tests, prostate biopsies, prostate cancer treatment (surgery and radiation), and urology visits were calculated per year among eligible men and stratified by age group. RESULTS A 59% decrease in PSA screening occurred among men aged ≥75 years beginning in 2008, followed by 49% in ages 65-74, 20% in ages 50-64, and 33% in ages 40-49 years in 2009. However, the number of elevated PSA tests remained largely unchanged in all groups except in men aged ≥75 years (45% decrease). Prostate biopsy rates and urology visits remained consistent among elderly men. CONCLUSION Among men in this managed care setting, although there was a sharp decline in PSA testing among men aged ≥75 years after 2008, prostate biopsy rates remained constant, and subsequent prostate cancer treatment remained highest among men in this age group. These results suggest that the guidelines recommending against PSA and the subsequent provider-targeted interventions implemented in this system resulted in decreased screening across age groups and potentially led to more discriminant screening among those aged ≥75 years.

Progression and treatment of incident lower urinary tract symptoms (LUTS) among men in the California Men's Health Study

To characterise the progression and treatment of lower urinary tract symptoms (LUTS) among men aged 45–69 years in the California Mens Health Study.

MP95-15 POPULATION MANAGEMENT KIDNEY STONE CARE APPROACH IMPROVES COMPLIANCE WITH THE AMERICAN UROLOGICAL ASSOCIATION (AUA) RECOMMENDATIONS ON MEDICAL MANAGEMENT OF KIDNEY STONES

INTRODUCTION AND OBJECTIVES: Stress may play a role in endocrinologic causes of kidney stones, be a consequence of stones, or both. We sought to determine if stress was correlated with healthrelated quality of life (HRQOL) in kidney stone patients with a multiinstitutional, prospective approach. METHODS: With IRB approval at participating sites, a subset of patients from the North American Stone Quality of Life Consortium were administered the Perceived Stress Scale (PSS-10) and the Wisconsin Stone Quality of Life (WISQOL) questionnaires. Both are validated, but WISQOL is a stone-specific, patient-reported outcome to assess HRQOL. WISQOL total and domain scores were compared with PSS10 scores. WISQOL and PSS-10 scores were also compared by patients’ stone and symptom statuses. RESULTS: Patients (n1⁄4114; M 56, F 58; age 55 15 y) from 3 centers participated; 78% were white Caucasian, 6% Hispanic/Latino, 11% Asian, and 4% Black/African American. Most (90%) were mixed calcium stone formers. Duration of stone disease varied (mean 10 y; median 4.5 y) as did patients’ estimated number of lifetime stone events (mean4.6;median2.0). Amongpatientswith active stone symptoms (27% of sample), total WISQOL and PSS-10 scores were inversely correlated (Pearson correlation coefficient, -0.235; P1⁄40.014), demonstrating that lower HRQOL was associated with more stress. Domain-level analysis revealed that lower HRQOL scores in domains 1 (emotional impact) and 4 (vitality) were also associated with more stress (P1⁄40.011 and 0.0065, respectively). While the WISQOL discriminated patients with stones at survey completion from patients without (P1⁄40.019 for difference in total scores), the PSS-10 did not (P1⁄40.73 for difference in PSS-10 scores). Similarly, the WISQOL distinguished symptomatic patients from asymptomatic (p<0.0001 for difference) while the PSS-10 could not (P1⁄40.46). CONCLUSIONS: The inverse relationship between the PSS-10 and WISQOL showed overall that patients with higher levels of stress had lower HRQOL. Patients with stone-related symptoms scored lower on the WISQOL for emotional impact and vitality than asymptomatic patients and had significantly more stress. Despite the association of stress and lower HRQOL in patients with stones and symptoms, stress alone did not explain the HRQOL differences between these groups. This study showed that stone patients with a lower HRQOL had more stress. A future comparison of stress levels in stone patients compared to non-stone forming controls may help us determine if stress has a reactive or causative role in kidney stone disease.

PD57-01 HEMATURIA RISK INDEX - RISK OF UROTHELIAL MALIGNANCY IN PATIENTS WITH ASYMPTOMATIC MICROSCOPIC HEMATURIA

CONCLUSIONS: Only a quarter of our respondents utilize FT in their practice with surgeon’s experience being the only independent predictor for utilizing FT. Majority of respondents though consider FT to be beneficial in prostate cancer management and would use it more often if provided more reliable and cost effective options. Over time, experience and accessibility to reliable methods to perform FT may lead to further utilization of this novel treatment strategy.

Identifying lifestyle and genetic factors to prevent recurrence of non-muscle invasive bladder cancer in a prospective cohort study at Kaiser Permanente (the Be-Well study).

e296 Background: Bladder cancer is one of the top 10 incident cancers. Most cases (75%) are diagnosed as non-muscle invasive disease (NMID), yet NMID typically recurs (70%) and a subset (25%) progresses to muscle-invasive disease. Be-Well is a 5-year, NCI-funded prospective cohort study of NMID bladder cancer patients at Kaiser Permanente Northern (KPNC) and Southern California (KPSC). The goal is to examine diet and lifestyle factors and prognosis, with an emphasis on cruciferous vegetable (CV) intake and their unique isothiocyanate (ITC) content, the modifying effect of polymorphisms of ITC-metabolizing genes, and interactions with treatment. Our prior work suggests that dietary ITCs may prevent disease recurrence and progression in NMID patients. METHODS Newly-diagnosed patients with NMID (Ta, Tis, T1), who are English-speaking, KP members, and ≥ 21 years of age, are rapidly ascertained from electronic pathology reports and enrolled on average 2.6 months post-diagnosis. Baseline participation consists of a telephone interview including a food frequency questionnaire focused on CV intake, and providing blood and urine samples. Patients will be contacted for follow-up interviews and urine samples at 12 and 24 months. Smoking, medication use, occupational exposures, physical activity, quality of life, and urinary function are also queried. Biospecimens are processed and assayed at Roswell Park Cancer Institute. Strong support for Be-Well by KP urologists will promote dissemination of study results in patient care and recommendations. RESULTS Recruitment began in February 2015. To date, 159 patients have completed the baseline interview, representing 76% male and 24% female, and 80% White, 8% Black, 6% Hispanic, 3% Asian, and 3% Other. Urine specimens have been collected from 87% of consented patients. Blood specimens have been collected from 87% of KPNC patients, with collection at KPSC to begin in Fall 2015. CONCLUSIONS The Be-Well Study is poised to be the largest and most comprehensive study to answer critical questions related to prognosis, quality of life, and care in patients diagnosed with early-stage bladder cancer.

The Continuum of Prostate Cancer Care: An Integrated Population Based Model of Health Care Delivery

Introduction: We present a comprehensive model for population based prostate cancer management that is scalable, and has improved quality and outcomes. Methods: Kaiser Permanente Southern California is an integrated health care system that provides comprehensive care for 3.7 million members. Beginning in 2003 we put programs into place to improve the spectrum of care related to prostate cancer. These programs addressed screening, shared decision making for treatment after diagnosis, and care improvement for men with localized and advanced disease. These were implemented with traditional quality improvement techniques and outcomes were evaluated in collaboration with research groups embedded in the organization. Results: Prostate cancer screening in men 75 years old or older decreased 50% from 30% to 15%. The Safety Net program identified nearly 1,200 men with prostate cancer who had not been seen for followup from 2006 to 2010. There was a reduction in blood loss in surgical procedures that obviated the need for transfusion while maintaining a low positive margin rate. Hormonal therapy was changed to a dosing approach that was based on circulating testosterone levels, preventing some of the side effects of this therapy. Coupled with a systems approach to osteoporosis prevention, this approach resulted in a dramatic reduction in fracture rates in this high risk population. Conclusions: These data demonstrate that a systems approach to a population based prostate cancer program can lead to efficient and reliable care that can be successfully disseminated through an integrated health plan.

Improving quality of prostate cancer care in an integrated care delivery system.

147 Background: Kaiser Permanente (KP) is an integrated care delivery system that provides clinical services to over 9 million members in nine states and the District of Columbia with the goal of providing high-quality and affordable health care to our patients. Over the last decade, the rapid adoption of prostate cancer (Pca) screening practice and technology have resulted in increased detection of Pca and helped identify opportunities for care improvement. KP initiated improvements of continuum of services provided to Pca patients. METHODS Transforming the care provided to Pca patients evolved into the first population-based cancer program that manages the entire continuum of care by taking advantage of our integrated health delivery system. Major accomplishments include appropriate Pca screening to prevent over-diagnosis (Prostate Cancer Screening), improved patient safety and claims reduction to prevent missed abnormal cancer screening (PSA Safety Net), comparative effectiveness of cancer treatment choices to improve quality, and benchmark outcomes in efficiency and clinical quality utilizing a new technology (Robotic Surgery). In addition, the program has achieved superior outcomes and value through innovative chemotherapy management for advanced disease (Lupron Management). Evidence-based medicine, research, analytics and continuous quality improvementare cornerstones of the program, while the pinnacle is our patients, who receive informed, shared decision making and equitable unbiased care. RESULTS We strongly believe that measures of how well our patients are living with Pca are as important as the cancer-specific survival measures; because of this, we established a prospective registry to measure quality of life for every newly diagnosed patient and stratified by all treatment types. This practice is being disseminated across the Program. CONCLUSIONS By systematically stratifying this diverse population, we have been able to achieve efficient reliable care, and spread each successful process to other regions through collaboration with KPs Interregional Chiefs of Urology.

Stratifying risk of urinary tract malignant tumors in patients with asymptomatic microscopic hematuria.

223 Background: AMH in the general population is common, occurring in up to 9-18%. Even low degrees of AMH have been considered a risk factor for UTMT. Although the prevalence of UTMT is low (.01-3%), many asymptomatic patients undergo unnecessary and hazardous evaluations. In 2007, the Kaiser Permanente (KP) Urologists started a multi-year QI effort to research and develop a risk stratified evidence-based approach in the evaluation of AMH. METHODS The group first conducted a retrospective analysis to determine the incidence of urinary cancer, and stratify risk according to age, gender, smoking history, and degree of hematuria. A multi-regional prospective, observational study was then conducted over a two year period. We used a data collection tool embedded within an EMR to determine patients with AMH who are at greatest risk for UTMT, and patients who might benefit from urologic evaluation or safely avoid unnecessary workup and radiation exposure. RESULTS 4,414 patients had full urologic work up. Overall, 100 bladder cancers were diagnosed among 4,414 patients (2.3%), and only 11 renal cancers (0.2%) were pathologically confirmed. Multivariable logistic regression was conducted for 5 common parameters: age, gender, smoking history, degree of microscopic hematuria, and history of gross hematuria within the past 6 months. The two most important risk factors were age > 50, and prior history of gross hematuria. A hematuria risk index (HRI) was developed, which significantly improved predictability (AUC = .809-HRI vs .532-AUA guideline). Overall, 32% of the population was identified as low risk with only 0.2% cancer detected; 14% of the population was identified as high risk, of whom 11.1% had a cancer diagnosed. CONCLUSIONS These results suggest that a considerable proportion of patients may safely avoid hazardous evaluation using multivariate risk stratification. An evidence-based algorithm was developed for the management of asymptomatic microscopic hematuria and implemented within KP. We expect to significantly improve patient safety and improve reliability of patient evaluation.