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Tsao PA, Burns JA, Entenman S, Kumbier K, Sparks J, Bohnert ASB, Skolarus TA, Caram MV. Mental health care utilization among veterans with castration-resistant prostate cancer receiving abiraterone or enzalutamide. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.e18680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e18680 Background: Abiraterone and enzalutamide are oral therapies widely used to treat men with castration-resistant prostate cancer (CRPC). Recent data have suggested potentially worsened quality of life and depression with use of enzalutamide compared to abiraterone. Because Veterans are at a higher risk for mental health conditions, we sought to compare mental health service utilization in Veterans with CRPC receiving enzalutamide to those receiving abiraterone. Methods: The Veterans Health Administration Corporate Data Warehouse was used to identify men with CRPC who received abiraterone or enzalutamide for ≥ 30 days as first-line treatment between 2010-2017. We compared the rate of mental health visits per 100 patient-months for men on abiraterone versus enzalutamide using an exact rate ratio test, assuming Poisson counts. Results: Among 2902 male Veterans, 68.6% (n=1992) received abiraterone and 31.4% (n=910) enzalutamide as first-line therapy. Men who received enzalutamide were older (76 vs 74, p<0.01) and had a higher comorbidity burden (Charlson Comorbidity Index [CCI] ≥ 2 in 28.7% vs 21.6%, p<0.01); no differences were noted in race or prevalence of preexisting documented mental health diagnoses. Median time on drug was 8 months for both medications. There was no difference in the rate of mental health visits per 100 patients-months on enzalutamide versus abiraterone (6.6 v. 6.7, p=0.66). However, within patient sub-groups, men who were age 75 or older, not married, or without notable comorbidities had lower rates of mental health visits with enzalutamide compared to abiraterone; whereas those who were younger than 75, married, had higher comorbidities, or a preexisting mental health diagnosis had higher rates of mental health visits with enzalutamide (Table). Conclusions: Among Veterans with CRPC who received a novel antiandrogen therapy first-line, there was no difference in engagement in mental health care between those who received abiraterone versus enzalutamide. Sub-group analysis revealed significant differences between patients on the two medications in demographic and diagnostic characteristics associated with number of visits, suggesting that vulnerability for mental health symptoms may vary by medication type. Further work in understanding the long-term impact of novel antiandrogens on mental health is needed.[Table: see text]
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Lamb BW, Miah S, Skolarus TA, Stewart GD, Green JSA, Sevdalis N, Soukup T. Development and Validation of a Short Version of the Metric for the Observation of Decision-Making in Multidisciplinary Tumor Boards: MODe-Lite. Ann Surg Oncol 2021; 28:7577-7588. [PMID: 33974197 PMCID: PMC8519835 DOI: 10.1245/s10434-021-09989-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 03/02/2021] [Indexed: 01/08/2023]
Abstract
Background Evidence-based tools are necessary for scientifically improving the way MTBs work. Such tools are available but can be difficult to use. This study aimed to develop a robust observational assessment tool for use on cancer multidisciplinary tumor boards (MTBs) by health care professionals in everyday practice. Methods A retrospective cross-sectional observational study was conducted in the United Kingdom from September 2015 to July 2016. Three tumor boards from three teaching hospitals were recruited, with 44 members overall. Six weekly meetings involving 146 consecutive cases were video-recorded and scored using the validated MODe tool. Data were subjected to reliability and validity analysis in the current study to develop a shorter version of the MODe. Results Phase 1, a reduction of the original items in the MODe, was achieved through two focus group meetings with expert assessors based on previous research. The 12 original items were reduced to 6 domains, receiving full agreement by the assessors. In phase 2, the six domains were subjected to item reliability, convergent validation, and internal consistency testing against the MODe-Lite global score, the MODe global score, and the items of the MODe. Significant positive correlations were evident across all domains (p < 0.01), indicating good reliability and validity. In phase 3, feasibility and high inter-assessor reliability were achieved by two clinical assessors. Six domains measuring clinical input, holistic input, clinical collaboration, pathology, radiology, and management plan were integrated into MODe-Lite. Conclusions As an evidence-based tool for health care professionals in everyday practice, MODe-Lite gives cancer MTBs insight into the way they work and facilitates improvements in practice. Supplementary Information The online version contains supplementary material available at 10.1245/s10434-021-09989-7.
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Cruz AP, Skolarus TA, Ambani SN, Hafez K, Kraft KH. Aligning Urology Residency Training With Real-World Workforce Needs. JOURNAL OF SURGICAL EDUCATION 2021; 78:820-827. [PMID: 33046414 PMCID: PMC7546236 DOI: 10.1016/j.jsurg.2020.09.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 08/25/2020] [Accepted: 09/26/2020] [Indexed: 05/09/2023]
Abstract
OBJECTIVE Research suggests recently graduated urology residents do not feel ready for independent practice. We conducted a study to determine if Accreditation Council for Graduate Medical Education (ACGME) minimum case requirements, resident case logs, and graduating resident perceived readiness for practice are aligned with the procedural demand and needs of the current urology workforce. DESIGN Correlative study comparing the association between (1) workforce demand and ACGME case requirements, and (2) workforce demand and perceived resident competency. Three distinct datasets were used; (1) the 2017 Medicare Part B National Summary Data File; (2) the 2017 National Data Report published by the ACGME; and (3) a graduating resident survey from Okhunov et al. SETTING: N/A. PARTICIPANTS N/A. RESULTS In 2017, there were a total of 6,784,696 urologic cases performed through Medicare. We found nonsignificant positive associations between resident case logs (rho = 0.16, p = 0.5784), ACGME minimum procedure requirements (rho = 0.42, p = 0.1255), and Medicare procedural demand. Our 15 index procedures accounted for 21.1% (n = 1,431,775) of all Medicare cases, with a median number of 7706 procedures. Endopyelotomy was the least common procedure (n = 98), while cystoscopy was the most common (n = 980,623). Medicare case volume was positively correlated with graduating residents' procedural confidence (r = 0.86, p < 0.0001). We identified four categories with varied alignment of training and demand: (1) high volume and high confidence, (2) high volume and low confidence, (3) low volume and high confidence, and (4) low volume and low confidence. CONCLUSIONS Optimizing urology residency training is time-sensitive and important. Using national Medicare data coupled with recently graduated urology resident survey results, we provide a guiding framework for improving the alignment of training with workforce demand. Informed by these results, we recommend altering training requirements to reflect these needs.
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Soukup T, Sevdalis N, Green JSA, Lamb BW, Chapman C, Skolarus TA. Making Tumor Boards More Patient-Centered: Let's Start With the Name. JCO Oncol Pract 2021; 17:591-593. [PMID: 33734827 DOI: 10.1200/op.20.00588] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
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Radhakrishnan A, Wallner LP, Skolarus TA, Abrahamse PH, Kollipara AS, Katz SJ, Hawley ST. Primary Care Providers' Perceptions About Participating in Low-Risk Prostate Cancer Treatment Decisions. J Gen Intern Med 2021; 36:447-454. [PMID: 33123958 PMCID: PMC7878590 DOI: 10.1007/s11606-020-06318-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 10/14/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Primary care provider's (PCP) role in cancer care is expanding and may include supporting patients in their treatment decisions. However, the degree to which PCPs engage in this role for low-risk prostate cancer is unknown. OBJECTIVE Characterize PCP perceptions regarding their role in low-risk prostate cancer treatment decision-making. DESIGN Cross-sectional, national survey. MAIN MEASURES For men with low-risk prostate cancer, PCP reports of (1) confidence in treatment decision-making (high vs. low); (2) intended participation in key aspects of active surveillance treatment decision-making (more vs. less). KEY RESULTS A total of 347 from 741 eligible PCPs responded (adjusted response rate 56%). Half of respondent PCPs (50.3%) reported high confidence about engaging in low-risk prostate cancer treatment decision-making. The odds of PCPs reporting high confidence were greater among those in solo practice (vs working with > 1 PCP) (OR 2.18; 95% CI 1.14-4.17) and with higher volume of prostate cancer patients (> 15 vs. 6-10 in past year) (OR 2.16; 95% CI 1.02-4.61). PCP report of their intended participation in key aspects of active surveillance treatment decision-making varied: discussing worry (62.4%), reviewing benefits (48.5%) and risks (41.8%), and reviewing all treatment options (34.2%). PCPs who reported high confidence had increased odds of more participation in all aspects of active surveillance decision-making: reviewing all treatment options (OR 3.11; 95% CI 1.82-5.32), discussing worry (OR 2.12; 95% CI 1.28-3.51), and reviewing benefits (OR 3.13; 95% CI 1.89-5.16) and risks (OR 3.20; 95% CI 1.91-5.36). CONCLUSIONS The majority of PCPs were confident about engaging with patients in low-risk prostate cancer treatment decision-making, though their intended participation varied widely across four key aspects of active surveillance care. With active surveillance being considered for other low-risk cancers (such as breast and thyroid), understanding factors influencing PCP involvement will be instrumental to supporting team-based cancer care.
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Stensland KD, DePorto K, Ryan J, Kaffenberger S, Reinstatler LS, Galsky M, Canes D, Skolarus TA, Moinzadeh A. Estimating the rate and reasons of clinical trial failure in urologic oncology. Urol Oncol 2020; 39:154-160. [PMID: 33257221 DOI: 10.1016/j.urolonc.2020.10.070] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 09/23/2020] [Accepted: 10/23/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Clinical trials are pillars of modern clinical evidence generation. However, the clinical trial enterprise can be inefficient, and trials often fail before their planned endpoint is reached. We sought to estimate how often urologic oncology trials fail, why trials fail, and associations with trial failure. METHODS We queried phase 2/3 urologic clinical trial data from ClinicalTrials.gov registered between 2007 and 2019, with status marked as active, completed, or terminated. We extracted relevant trial data, including anticipated and actual accrual, from trial records and ClinicalTrials.gov archives. We manually coded reasons given in the "why stopped" free text field for trial failure into categories (poor accrual, interim results, toxicity/adverse events, study agent unavailable, canceled by the sponsor, inadequate budget, logistics, trial no longer needed, principal investigator left, no reason given, or other). We considered trials terminated for safety or efficacy to be completed trials. Trials marked as terminated for other reasons were considered failed trials. We then estimated the rate of trial failure using competing risks methods. Finally, we assessed associations with trial failure using a Cox proportional hazards model. RESULTS A total of 1,869 urologic oncology trials were included. Of these, 225 (12.0%) failed, and 51 (2.7%) were terminated for "good" reasons (e.g., toxicity, efficacy). Of the 225 failed trials, 122 (54%) failed due to poor accrual. Failed trials had a lower anticipated accrual than successfully completed trials (55 vs. 63 patients, P<0.001). A total of 6,832 patients were actually accrued to failed trials. The 10-year estimated risk of trial failure was 17% (95% CI 15%-22%). Single center trials, phase 3 trials, drug trials, and trials with exclusively USA sites were more likely to fail. CONCLUSION We estimate that 17%, or roughly 1 in 6, of urologic oncology trials fail, most frequently for poor accrual. Further investigations are needed into systemic, trial, and site-specific factors that may impact accrual and successful trial completion.
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Caram MEV, Oerline MK, Dusetzina S, Herrel LA, Modi PK, Kaufman SR, Skolarus TA, Hollenbeck BK, Shahinian V. Adherence and out-of-pocket costs among Medicare beneficiaries who are prescribed oral targeted therapies for advanced prostate cancer. Cancer 2020; 126:5050-5059. [PMID: 32926427 DOI: 10.1002/cncr.33176] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 07/16/2020] [Accepted: 07/17/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND Abiraterone and enzalutamide are high-cost oral therapies that increasingly are used to treat patients with advanced prostate cancer; these agents carry the potential for significant financial consequences to patients. In the current study, the authors investigated coping and material measures of the financial hardship of these therapies among patients with Medicare Part D coverage. METHODS The authors performed a retrospective cohort study on a 20% sample of Medicare Part D enrollees who underwent treatment with abiraterone or enzalutamide between July 2013 and June 2015. The authors described the variability in adherence rates and out-of-pocket payments among hospital referral regions in the first 6 months of therapy and determined whether adherence and out-of-pocket payments were associated with patient factors and the socioeconomic characteristics of where a patient was treated. RESULTS There were 4153 patients who filled abiraterone or enzalutamide prescriptions through Medicare Part D in 228 hospital referral regions. The mean adherence rate was 75%. The median monthly out-of-pocket payment for abiraterone and enzalutamide was $706 (range, $0-$3505). After multilevel, multivariable adjustment for patient and regional factors, adherence was found to be lower in patients who were older (69% for patients aged ≥85 years vs 76% for patients aged <70 years; P < .01) and in those with low-income subsidies (69% in those with a subsidy vs 76% in those without a subsidy; P < .01). Both Hispanic ethnicity and living in a hospital referral region with a higher percentage of Hispanic beneficiaries were found to be independently associated with higher out-of-pocket payments for abiraterone and enzalutamide. CONCLUSIONS There were substantial variations in the adherence rate and out-of-pocket payments among Medicare Part D beneficiaries who were prescribed abiraterone and enzalutamide. Sociodemographic patient and regional factors were found to be associated with both adherence and out-of-pocket payments.
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Kaye DR, Schafer C, Thelen-Perry S, Parker C, Iglay-Reger H, Daignault-Newton S, Qin Y, Morgan TM, Weizer AZ, Kaffenberger SD, Herrel LA, Hafez KS, Lee CT, Skolarus TA, Englesbe MJ, Montgomery JS. The Feasibility and Impact of a Presurgical Exercise Intervention Program (Prehabilitation) for Patients Undergoing Cystectomy for Bladder Cancer. Urology 2020; 145:106-112. [DOI: 10.1016/j.urology.2020.05.104] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Revised: 04/21/2020] [Accepted: 05/17/2020] [Indexed: 01/22/2023]
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Baskin AS, Wang T, Berlin NL, Skolarus TA, Dossett LA. Scope and Characteristics of Choosing Wisely in Cancer Care Recommendations by Professional Societies. JAMA Oncol 2020; 6:1463-1465. [PMID: 32701128 PMCID: PMC7378871 DOI: 10.1001/jamaoncol.2020.2066] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 04/21/2020] [Indexed: 11/14/2022]
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Sohlberg EM, Thomas IC, Yang J, Kapphahn K, Daskivich TJ, Skolarus TA, Shelton JB, Makarov DV, Bergman J, Bang CK, Goldstein MK, Wagner TH, Brooks JD, Desai M, Leppert JT. Life expectancy estimates for patients diagnosed with prostate cancer in the Veterans Health Administration. Urol Oncol 2020; 38:734.e1-734.e10. [PMID: 32674954 DOI: 10.1016/j.urolonc.2020.05.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 02/28/2020] [Accepted: 05/11/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE Accurate life expectancy estimates are required to inform prostate cancer treatment decisions. However, few models are specific to the population served or easily implemented in a clinical setting. We sought to create life expectancy estimates specific to Veterans diagnosed with prostate cancer. MATERIALS AND METHODS Using national Veterans Health Administration electronic health records, we identified Veterans diagnosed with prostate cancer between 2000 and 2015. We abstracted demographics, comorbidities, oncologic staging, and treatment information. We fit Cox Proportional Hazards models to determine the impact of age, comorbidity, cancer risk, and race on survival. We stratified life expectancy estimates by age, comorbidity and cancer stage. RESULTS Our analytic cohort included 145,678 patients. Survival modeling demonstrated the importance of age and comorbidity across all cancer risk categories. Life expectancy estimates generated from age and comorbidity data were predictive of overall survival (C-index 0.676, 95% CI 0.674-0.679) and visualized using Kaplan-Meier plots and heatmaps stratified by age and comorbidity. Separate life expectancy estimates were generated for patients with localized or advanced disease. These life expectancy estimates calibrate well across prostate cancer risk categories. CONCLUSIONS Life expectancy estimates are essential to providing patient-centered prostate cancer care. We developed accessible life expectancy estimation tools for Veterans diagnosed with prostate cancer that can be used in routine clinical practice to inform medical-decision making.
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Berlin NL, Skolarus TA, Kerr EA, Dossett LA. Too Much Surgery: Overcoming Barriers to Deimplementation of Low-value Surgery. Ann Surg 2020; 271:1020-1022. [PMID: 32209904 DOI: 10.1097/sla.0000000000003792] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Urish KL, Qin Y, Salka B, Li BY, Borza T, Sessine M, Kirk P, Hollenbeck BK, Helm JE, Lavieri MS, Skolarus TA, Jacobs BL. Comparison of readmission and early revision rates as a quality metric in total knee arthroplasty using the Nationwide Readmission Database. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:687. [PMID: 32617307 PMCID: PMC7327322 DOI: 10.21037/atm-19-3463] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background After release of the Comprehensive Care for Joint Replacement bundle, there has been increased emphasis on reducing readmission rates for total knee arthroplasty (TKA). The potential for a separate, clinically-relevant metric, TKA revision rates within a year following surgery, has not been fully explored. Based on this, we compared rates and payments for TKA readmission and revision procedures as metrics for improving quality and cost. Methods We utilized the 2013 Nationwide Readmission Database (NRD) to examine national readmission and revision rates, the reasons for revision procedures, and associated costs for elective TKA procedures. As data are not linked across years, we examined revision rates for TKA completed in the month of January by capturing revision procedures in the subsequent following 11-month period to approximate a 1-year revision rate. Diagnosis and procedure codes for revision procedures were collected. Average readmission and revision procedure costs were then calculated, and the cost distributed across the entire TKA population. Results We identified 20,851 patients having TKA surgery. The mean unadjusted 30- and 90-day TKA readmission rates were 3.4% and 5.8%, respectively. In contrast, the mean unadjusted 3-month and approximate 1-year reoperation rates were 1.0% and 1.6%, respectively. The most common cause for revision was periprosthetic joint infection, which accounting for 62% of all reported revision procedures. The mean payment for 90-day readmission was roughly half ($10,589±$11,084) of the mean inpatient payment for single reoperation procedure at 90 days ($20,222±$17,799). Importantly, nearly half (46%) of all 90-day readmissions were associated with a reoperation event within the first year. Conclusions Readmission following TKA is associated with a 1-year reoperation in approximately half of patients. These reoperations represent a significant patient burden and have a higher per episode cost. Early reoperation may represent a more clinically relevant target for quality improvement and cost containment.
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Soukup T, Morbi A, Lamb BW, Gandamihardja TAK, Hogben K, Noyes K, Skolarus TA, Darzi A, Sevdalis N, Green JSA. A measure of case complexity for streamlining workflow in multidisciplinary tumor boards: Mixed methods development and early validation of the MeDiC tool. Cancer Med 2020; 9:5143-5154. [PMID: 32476281 PMCID: PMC7367630 DOI: 10.1002/cam4.3026] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 03/12/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE There is increasing emphasis in cancer care globally for care to be reviewed and managed by multidisciplinary teams (ie, in tumor boards). Evidence and recommendations suggest that the complexity of each patient case needs to be considered as care is planned; however, no tool currently exists for cancer teams to do so. We report the development and early validation of such a tool. METHODS We used a mixed-methods approach involving psychometric evaluation and expert review to develop the Measure of case-Discussion Complexity (MeDiC) between May 2014 and November 2016. The study ran in six phases and included ethnographic interviews, observations, surveys, feasibility and reliability testing, expert consensus, and multiple expert-team reviews. RESULTS Phase-1: case complexity factors identified through literature review and expert interviews; Phase-2: 51 factors subjected to iterative review and content validation by nine cancer teams across four England Trusts with nine further items identified; Phase 3: 60 items subjected to expert review distilled to the most relevant; Phase 4: item weighing and further content validation through a national UK survey; Phases 5 and 6: excellent interassessor reliability between clinical and nonclinical observers, and adequate validity on 903 video case discussions achieved. A final set of 27 factors, measuring clinical and logistical complexities were integrated into MeDiC. CONCLUSIONS MeDiC is an evidence-based and expert-driven tool that gauges the complexity of cancer cases. MeDiC may be used as a clinical quality assurance and screening tool for tumor board consideration through case selection and prioritization.
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Sessine MS, Weizer A, Kirk PS, Borza T, Jacobs BL, Qin Y, Oerline M, Li B, Modi PK, Lavieri MS, Gilbert SM, Montgomery JS, Hollenbeck BK, Urish K, Helm JE, Skolarus TA. Reframing Financial Incentives Around Reducing Readmission After Radical Cystectomy. Urology 2020; 142:99-105. [PMID: 32413517 DOI: 10.1016/j.urology.2020.03.059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 02/29/2020] [Accepted: 03/29/2020] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To better understand the financial implications of readmission after radical cystectomy, an expensive surgery coupled with a high readmission rate. Currently, whether hospitals benefit financially from readmissions after radical cystectomy remains unclear, and potentially obscures incentives to invest in readmission reduction efforts. MATERIALS AND METHODS Using a 20% sample of national Medicare beneficiaries, we identified 3544 patients undergoing radical cystectomy from January 2010 to November 2014. We compared price-standardized Medicare payments for index admissions and readmissions after surgery. We also examined the variable financial impact of length of stay and the proportion of Medicare payments coming from readmissions based on overall readmission rate. RESULTS Medicare patients readmitted after cystectomy had higher index hospitalization payments ($19,164 readmitted vs $18,146 non-readmitted, P = .03) and an average readmission payment of $7356. Adjusted average Medicare readmission payments and length of stay varied significantly across hospitals, ranging from $2854 to $15,605, and 2.0 to 17.1 days, respectively (both P <.01), with longer length of stay associated with increased payments. After hospitals were divided into quartiles based on overall readmission rates, the percent of payments coming from readmissions ranged from 5% to 13%. CONCLUSION Readmissions following radical cystectomy were associated with increased Medicare payments for the index hospitalization, and the readmission payment, potentially limiting incentives for readmission reduction programs. Our findings highlight opportunities to reframe efforts to support patients, caregivers, and providers through improving the discharge and readmission processes to create a patient-centered experience, rather than for fear of financial penalties.
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Caram MV, Oerline M, Dusetzina S, Modi PK, Herrel LA, Skolarus TA, Hollenbeck BK, Shahinian VB. Financial hardship among Medicare beneficiaries prescribed oral targeted therapies for advanced prostate cancer. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.6_suppl.68] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
68 Background: Abiraterone and enzalutamide are increasingly being used to treat advanced prostate cancer. Understanding barriers to adhering to treatment is of paramount importance in ensuring continued access to these important therapies. Patients with limited resources or insufficient access to mechanisms that lower their out-of-pocket cost are likely to suffer from significant financial toxicity and may engage in coping mechanisms such as rationing or abandoning their medication. Methods: To address the variability in measures of financial hardship, we performed a retrospective cohort study on a 20% sample of patients eligible for Medicare Part D who received their first fill of abiraterone or enzalutamide between July 2013 and June 2015. Patients were assigned to a provider based on their first prescription, and a hospital referral region (HRR) based on their ZIP code. The primary outcomes were to determine the proportion of days covered (PDC), overall prescription adherence, and average monthly out-of-pocket cost to patients prescribed abiraterone or enzalutamide, all within the first six months of treatment. Results: From mid-2013 to mid-2015, 4529 patients filled abiraterone or enzalutamide through Medicare Part D, within 305 HRRs. There was substantial variability in PDC, adherence, and out-of-pocket cost to patients among HRRs. The mean PDC was 84% with mean adherence of 73%, which included the 393 (8.7%) of patients who abandoned oral therapy after 1-2 fills. The median standard monthly out-of-pocket cost was $707, ranging between $0 and $3505. Among patients with low-income subsidies, median out-of-pocket cost by HRR ranged from $0 to $2815. We observed that PDC tracked closely with socioeconomic status – HRRs that included a higher proportion of patients eligible for Medicaid had lower PDCs and adherence, but lower standard out-of-pocket cost. Conclusions: This investigation demonstrated significant variation in PDC, adherence, and out-of-pocket cost among different HRRs for patients prescribed abiraterone and enzalutamide and that much of the variability in financial hardship measures among HRRs may be due to socioeconomic variables and regional variability.
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Paniagua Cruz A, Zhu KY, Ellimoottil C, Dauw CA, Sarma A, Skolarus TA. Characterizing the Benign Prostatic Hyperplasia Literature: A Bibliometric Analysis. Urology 2020; 136:202-211. [DOI: 10.1016/j.urology.2019.11.033] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 10/21/2019] [Accepted: 11/25/2019] [Indexed: 11/25/2022]
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Kirk PS, Liu X, Borza T, Li BY, Sessine M, Zhu K, Lesse O, Qin Y, Jacobs B, Urish K, Helm J, Gilbert S, Weizer A, Montgomery J, Hollenbeck BK, Lavieri M, Skolarus TA. Dynamic readmission prediction using routine postoperative laboratory results after radical cystectomy. Urol Oncol 2020; 38:255-261. [PMID: 31953004 DOI: 10.1016/j.urolonc.2019.11.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Revised: 10/19/2019] [Accepted: 11/25/2019] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To determine if the addition of electronic health record data enables better risk stratification and readmission prediction after radical cystectomy. Despite efforts to reduce their frequency and severity, complications and readmissions following radical cystectomy remain common. Leveraging readily available, dynamic information such as laboratory results may allow for improved prediction and targeted interventions for patients at risk of readmission. METHODS We used an institutional electronic medical records database to obtain demographic, clinical, and laboratory data for patients undergoing radical cystectomy. We characterized the trajectory of common postoperative laboratory values during the index hospital stay using support vector machine learning techniques. We compared models with and without laboratory results to assess predictive ability for readmission. RESULTS Among 996 patients who underwent radical cystectomy, 259 patients (26%) experienced a readmission within 30 days. During the first week after surgery, median daily values for white blood cell count, urea nitrogen, bicarbonate, and creatinine differentiated readmitted and nonreadmitted patients. Inclusion of laboratory results greatly increased the ability of models to predict 30-day readmissions after cystectomy. CONCLUSIONS Common postoperative laboratory values may have discriminatory power to help identify patients at higher risk of readmission after radical cystectomy. Dynamic sources of physiological data such as laboratory values could enable more accurate identification and targeting of patients at greatest readmission risk after cystectomy. This is a proof of concept study that suggests further exploration of these techniques is warranted.
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Hugar LA, Borza T, Oerline MK, Hollenbeck BK, Skolarus TA, Jacobs BL. Resurrecting immortal-time bias in the study of readmissions. Health Serv Res 2019; 55:273-276. [PMID: 31880314 DOI: 10.1111/1475-6773.13252] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE To compare readmission rates as measured by the Centers for Medicare and Medicaid Services and the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) methods. DATA SOURCES 20 percent sample of national Medicare data for patients undergoing cystectomy, colectomy, abdominal aortic aneurysm (AAA) repair, and total knee arthroplasty (TKA) between 2010 and 2014. STUDY DESIGN Retrospective cohort study comparing 30-day readmission rates. DATA COLLECTION/EXTRACTION METHODS Patients undergoing cystectomy, colectomy, abdominal aortic aneurysm repair, and total knee arthroplasty between 2010 and 2014 were identified. PRINCIPAL FINDINGS Cystectomy had the highest and total knee arthroplasty had the lowest readmission rate. The NSQIP measure reported significantly lower rates for all procedures compared to the CMS measure, which reflects an immortal-time bias. CONCLUSIONS We found significantly different readmission rates across all surgical procedures when comparing CMS and NSQIP measures. Longer length of stay exacerbated these differences. Uniform outcome measures are needed to eliminate ambiguity and synergize research and policy efforts.
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Macleod LC, Fam MM, Yabes JG, Hale NE, Turner RM, Lopa SH, Gingrich JR, Borza T, Skolarus TA, Davies BJ, Jacobs BL. Comparison of Neoadjuvant and Adjuvant Chemotherapy in Muscle-invasive Bladder Cancer. Clin Genitourin Cancer 2019; 18:201-209.e2. [PMID: 31917172 DOI: 10.1016/j.clgc.2019.12.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 12/05/2019] [Accepted: 12/09/2019] [Indexed: 12/01/2022]
Abstract
BACKGROUND We use observational methods to compare impact of perioperative chemotherapy timing (ie, neoadjuvant and adjuvant) on overall survival (OS) in muscle-invasive bladder cancer because there is no head-to-head randomized trial, and patient factors may influence decision-making. PATIENTS AND METHODS Using Surveillance, Epidemiology, and End Results-Medicare data, we identified patients receiving cystectomy for muscle-invasive bladder cancer diagnosed between 2004 and 2013. Patients were classified as receiving neoadjuvant or adjuvant chemotherapy. Propensity of receiving neoadjuvant chemotherapy was determined using gradient boosted models. Inverse probability of treatment weighted survival curves were adjusted for 13 demographic, socioeconomic, temporal, and oncologic covariates. RESULTS We identified 1342 patients who received neoadjuvant (n = 676) or adjuvant chemotherapy (n = 666) with a median follow-up of 23 months (interquartile range, 9-55 months). Inverse probability of treatment weighted adjustment allows comparison of the groups head-to-head as well as counterfactual scenarios (eg, effect if those getting one treatment were to receive the other). The average treatment effect (ie, "head-to-head" comparison) of adjuvant compared with neoadjuvant on OS was not significant (hazard ratio, 1.14; 95% confidence interval, 0.99-1.31). However, the average treatment effect of the treated (ie, the effect if the neoadjuvant patients were to receive adjuvant instead) was associated with a 33% increase in risk of mortality if they were given adjuvant therapy instead (hazard ratio, 1.33; 95% confidence interval, 1.12-1.57). CONCLUSION Significant treatment selection bias was noted in peri-cystectomy timing, which limits the ability to discriminate differential efficacy of these 2 approaches with observational data. However, patients with higher propensity to receive neoadjuvant therapy were predicted to have increased OS with approach, in keeping with existing paradigms from trial data.
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Skolarus TA, Dauw CA, Fowler KE, Mann JD, Bernstein SJ, Meddings J. Catheter management after benign transurethral prostate surgery: RAND/UCLA Appropriateness Criteria. THE AMERICAN JOURNAL OF MANAGED CARE 2019; 25:e366-e372. [PMID: 31860230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVES To formally assess the appropriateness of different timings of urethral catheter removal after transurethral prostate resection or ablation. Although urethral catheter placement is routine after this common treatment for benign prostatic hyperplasia (BPH), no guidelines inform duration of catheter use. STUDY DESIGN RAND/UCLA Appropriateness Methodology. METHODS Using a standardized, multiround rating process (ie, the RAND/UCLA Appropriateness Methodology), an 11-member multidisciplinary panel reviewed a literature summary and rated clinical scenarios for urethral catheter duration after transurethral prostate surgery for BPH as appropriate (ie, benefits outweigh risks), inappropriate, or of uncertain appropriateness. We examined appropriateness across 4 clinical scenarios (no preexisting catheter, preexisting catheter [including intermittent], difficult catheter placement, significant perforation) and 5 durations (postoperative day [POD] 0, 1, 2, 3-6, or ≥7). RESULTS Urethral catheter removal and first trial of void on POD 1 was rated appropriate for all scenarios except clinically significant perforations. In this case, waiting until POD 3 was deemed the earliest appropriate timing. Waiting 3 or more days to remove the catheter for patients with or without preexisting catheter needs, or for those with difficult catheter placement in the operating room, was rated as inappropriate. CONCLUSIONS We defined clinically relevant guidance statements for the appropriateness of urethral catheter duration after transurethral prostate surgery. Given the lack of guidelines and this robust expert panel approach, these ratings may help clinicians and healthcare systems improve the consistency and quality of care for patients undergoing transurethral surgery for BPH.
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Hale NE, Macleod LC, Yabes JG, Turner RM, Fam MM, Gingrich JR, Skolarus TA, Borza T, Sabik LM, Davies BJ, Jacobs BL. Implications of Cystectomy Travel Distance for Hospital Readmission and Survival. Clin Genitourin Cancer 2019; 17:e1171-e1180. [DOI: 10.1016/j.clgc.2019.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Revised: 08/03/2019] [Accepted: 08/10/2019] [Indexed: 12/19/2022]
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Chapman CH, Caram MEV, Radhakrishnan A, Tsodikov A, Deville C, Burns J, Zaslavsky A, Chang M, Leppert JT, Hofer T, Sales AE, Hawley ST, Hollenbeck BK, Skolarus TA. Association between PSA values and surveillance quality after prostate cancer surgery. Cancer Med 2019; 8:7903-7912. [PMID: 31691526 PMCID: PMC6912050 DOI: 10.1002/cam4.2663] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 10/14/2019] [Accepted: 10/15/2019] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Although prostate-specific antigen (PSA) testing is used for prostate cancer detection and posttreatment surveillance, thresholds in these settings differ. The screening cutoff of 4.0 ng/mL may be inappropriately used during postsurgery surveillance, where 0.2 ng/mL is typically used, creating missed opportunities for effective salvage radiation treatment. We performed a study to determine whether guideline concordance with annual postoperative PSA surveillance increases when PSA values exceed 4 ng/mL, which represents a screening threshold that is not relevant after surgery. METHODS We used US Veterans Health Administration data to perform a retrospective longitudinal cohort study of men diagnosed with nonmetastatic prostate cancer from 2005 to 2008 who underwent radical prostatectomy. We used logistic regression to examine the association between postoperative PSA levels and receipt of an annual PSA test. RESULTS Among 10 400 men and 38 901 person-years of follow-up, annual guideline concordance decreased from 95% in year 1 to 79% in year 7. After adjustment, guideline concordance was lower for the youngest and oldest men, Black, and unmarried men. Guideline concordance significantly increased as PSA exceeded 4 ng/mL (adjusted odds ratio 2.20 PSA > 4-6 ng/mL vs PSA > 1-4 ng/mL, 95% confidence interval 1.20-4.03; P = .01). CONCLUSIONS Guideline concordance with prostate cancer surveillance increased when PSA values exceeded 4 ng/mL, suggesting a screening threshold not relevant after prostate cancer surgery, where 0.2 ng/mL is considered treatment failure, is impacting cancer surveillance quality. Clarification of PSA thresholds for early detection vs cancer surveillance, as well as emphasizing adherence for younger and Black men, appears warranted.
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Li BY, Urish KL, Jacobs BL, He C, Borza T, Qin Y, Min HS, Dupree JM, Ellimoottil C, Hollenbeck BK, Lavieri MS, Helm JE, Skolarus TA. Inaugural Readmission Penalties for Total Hip and Total Knee Arthroplasty Procedures Under the Hospital Readmissions Reduction Program. JAMA Netw Open 2019; 2:e1916008. [PMID: 31755949 PMCID: PMC6902819 DOI: 10.1001/jamanetworkopen.2019.16008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
IMPORTANCE The Hospital Readmissions Reduction Program (HRRP) is a Centers for Medicare and Medicaid Services policy that levies hospital reimbursement penalties based on excess readmissions of patients with 4 medical conditions and 3 surgical procedures. A greater understanding of factors associated with the 3 surgical reimbursement penalties is needed for clinicians in surgical practice. OBJECTIVE To investigate the first year of HRRP readmission penalties applied to 2 surgical procedures-elective total hip arthroplasty (THA) and total knee arthroplasty (TKA)-in the context of hospital and patient characteristics. DESIGN, SETTING, AND PARTICIPANTS Fiscal year 2015 HRRP penalization data from Hospital Compare were linked with the American Hospital Association Annual Survey and with the Healthcare Cost and Utilization Project State Inpatient Database for hospitals in the state of Florida. By using a case-control framework, those hospitals were separated based on HRRP penalty severity, as measured with the HRRP THA and TKA excess readmission ratio, and compared according to orthopedic volume as well as hospital-level and patient-level characteristics. The first year of HRRP readmission penalties applied to surgery in Florida Medicare subsection (d) hospitals was examined, identifying 60 663 Medicare patients who underwent elective THA or TKA in 143 Florida hospitals. The data analysis was conducted from February 2016 to January 2017. EXPOSURES Annual hospital THA and TKA volume, other hospital-level characteristics, and patient factors used in HRRP risk adjustment. MAIN OUTCOMES AND MEASURES The HRRP penalties with HRRP excess readmission ratios were measured, and their association with annual THA and TKA volume, a common measure of surgical quality, was evaluated. The HRRP penalties for surgical care according to hospital and readmitted patient characteristics were then examined. RESULTS Among 143 Florida hospitals, 2991 of 60 663 Medicare patients (4.9%) who underwent THA or TKA were readmitted within 30 days. Annual hospital arthroplasty volume seemed to follow an inverse association with both unadjusted readmission rates (r = -0.16, P = .06) and HRRP risk-adjusted readmission penalties (r = -0.12, P = .14), but these associations were not statistically significant. Other hospital characteristics and readmitted patient characteristics were similar across HRRP orthopedic penalty severity. CONCLUSIONS AND RELEVANCE This study's findings suggest that higher-volume hospitals had less severe, but not significantly different, rates of readmission and HRRP penalties, without systematic differences across readmitted patients.
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MESH Headings
- Aged
- Arthroplasty, Replacement, Hip/adverse effects
- Arthroplasty, Replacement, Hip/statistics & numerical data
- Arthroplasty, Replacement, Knee/adverse effects
- Arthroplasty, Replacement, Knee/statistics & numerical data
- Case-Control Studies
- Centers for Medicare and Medicaid Services, U.S./economics
- Centers for Medicare and Medicaid Services, U.S./standards
- Female
- Florida
- Humans
- Male
- Patient Readmission/economics
- Patient Readmission/statistics & numerical data
- Reimbursement Mechanisms/economics
- Reimbursement Mechanisms/organization & administration
- Risk Adjustment
- United States
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Borza T, Oreline MK, Skolarus TA, Norton EC, Ryan AM, Ellimoottil C, Dimick JB, Shahinian VB, Hollenbeck BK. Association of the Hospital Readmissions Reduction Program With Surgical Readmissions. JAMA Surg 2019; 153:243-250. [PMID: 29167870 DOI: 10.1001/jamasurg.2017.4585] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Modi PK, Kaufman SR, Herrel LA, Dupree JM, Luckenbaugh AN, Skolarus TA, Hollenbeck BK, Shahinian VB. Practice-Level Adoption of Conservative Management for Prostate Cancer. J Oncol Pract 2019; 15:e863-e869. [PMID: 31509481 DOI: 10.1200/jop.19.00088] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
PURPOSE We describe the longitudinal adoption of conservative management (ie, the absence of treatment) for prostate cancer among urology group practices in the United States and identify group practice features that influence this adoption. METHODS Using a 20% sample of Medicare claims, we identified men with incident prostate cancer from 2010 through 2014 and assigned each to his predominant urologist. We linked each urologist to a practice and characterized the practice's organization (eg, solo, single specialty, multispecialty) and ownership of intensity-modulated radiation therapy. For each group, we determined the rate of conservative management within 1 year of diagnosis. We then fit mixed-effects logistic regression models to assess relationships between practice organization and the adoption of conservative management over time, adjusted for patient characteristics. RESULTS We identified 22,178 men with newly diagnosed prostate cancer managed by 350 practices. Practices that increased use the most over time also used conservative management the most in 2010, whereas those that increased use the least used conservative management the least in 2010. Thus, the difference in average use of conservative management between highest- and lowest-use practices widened between 2010 and 2014. Urology groups increased their use of conservative management more rapidly than multispecialty groups. There was no difference in the rate of increase between intensity-modulated radiation therapy owning and nonowning groups. CONCLUSION There is increasing variation among group practices in the use of conservative management for prostate cancer. This underscores the need for a better understanding of practice-level factors that influence prostate cancer management.
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