Best of AUA 2013: Outcomes Analysis

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Presented by Danil V. Makarov, MD, MHS

NYU School of Medicine, New York

•  Obesity, sedentary lifestyle, and diabetes are associated with increased risk of stone disease. Severity of diabetes and quality of its management were associated with likelihood of stone disease, with pre-diabetic patients having a lower risk for stones than those with diabetic range hemoglobin A1c.

•  Obesity, physical inactivity, and high caloric intake are independently associated with increased risk of stone disease in women.

•  A randomized trial comparing robotic and open cystectomy showed no difference in complications and no difference in oncologic outcomes.

•  In an analysis of treatment regimens for metastatic castrate-resistant prostate cancer that assumed a societal threshold of willingness to pay of $100,000 per life year gained, all current therapeutic strategies exceeded societal willingness to pay. Cost-effectiveness analyses, which are used in other countries to determine drug coverage, may become increasingly important in the United States as well.

•  Older age and poor health were associated with non-definitive treatment of localized prostate cancer in both an older (1994-1995) and a more recent (2011-2012) cohort. African-American race was significantly associated with non-definitive treatment in the older cohort but not in the modern cohort, suggesting a less significant disparity in treatment selection.

• Disparities in prostate cancer may not be dead yet. A systematic review of all randomized controlled trials of prostate cancer treatment from 2002 to 2011 found only 22% of trials enrolled African-American men. The highest fraction enrolled were in U.S. trials (44% vs. 8% for the rest of the world), but there was no significant change in this percentage over time.

•  Use of quality indicators is an effective way to document, benchmark, and improve care, including care of women with urinary incontinence. Assessment of care among a vulnerable elders primary care cohort and a multispecialty group practice cohort found that while the multispecialty group practice produced better quality indicator scores, overall care was inadequate on multiple domains.

• The Surgical Consumer Assessment of Healthcare Providers and Systems (S-CAHPS) survey correlated very well with overall surgeon satisfaction, while postoperative care correlated more closely with postoperative office visit communication. Hospital CAHPS (H-CAHPS) survey reporting is currently tied to payment incentives, and S-CAHPS will likely be as well.

•  In regions that acquired new ambulatory surgery centers (ASCs), hospital volumes of urologic procedures declined, as did mortality rates for urologic procedures. Thus, the goals of ASC establishment were met, but the costs to society have yet to be assessed.

•  In a study aimed at improving judicious use of intravesical chemotherapy (IVC) for nonmuscle-invasive bladder cancer, researchers attempted to increase use for ideal cases and, for non-ideal cases, examined use of IVC at baseline and after an intervention that included feedback of utilization data and review of clinical guidelines. They found little change after the intervention, that intravesical chemotherapy is already being used judiciously, and a potential ceiling effect with small potential for benefit.

• Inappropriate use of imaging to stage incident prostate cancer declined significantly over 10 years-from 45% to 3%-in a Swedish program that included dissemination of utilization data and contemporary imaging guidelines to urologists. There was also a small decline in appropriate imaging.UT

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