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Kaye DR, Khilfeh I, Muser E, Morrison L, Kinkead F, Urosevic A, Lefebvre P, Pilon D, George DJ. Real-world economic burden of metastatic castration-resistant prostate cancer before and after first-line therapy initiation. J Med Econ 2024; 27:201-214. [PMID: 38204397 DOI: 10.1080/13696998.2024.2303890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 01/08/2024] [Indexed: 01/12/2024]
Abstract
AIMS To describe healthcare costs of patients with metastatic castration-resistant prostate cancer (mCRPC) initiating first-line (1 L) therapies from a US payer perspective. METHODS Patients initiating a Flatiron oncologist-defined 1 L mCRPC therapy (index date) on or after mCRPC diagnosis were identified from linked electronic medical records/claims data from the Flatiron Metastatic Prostate Cancer (PC) Core Registry and Komodo's Healthcare Map. Patients were excluded if they initiated a clinical trial drug in 1 L, had <12 months of insurance eligibility prior to index, or no claims in Komodo's Healthcare Map for the Flatiron oncologist-defined index therapy. All-cause and PC-related total costs per-patient-per-month (PPPM), including costs for services and procedures from medical claims (i.e. medical costs) and costs from pharmacy claims (i.e. pharmacy costs), were described in the 12-month baseline period before 1 L therapy initiation (including the baseline pre- and post- mCRPC progression periods) and during 1 L therapy (follow-up). RESULTS Among 459 patients with mCRPC (mean age 70 years, 57% White, 16% Black, 45% commercially-insured, 43% Medicare Advantage-insured, and 12% Medicaid-insured), average baseline all-cause total costs (PPPM) were $4,576 ($4,166 pre-mCRPC progression, $8,278 post-mCRPC progression). Average baseline PC-related total costs were $2,935 ($2,537 pre-mCRPC progression, $6,661 post-mCRPC progression). During an average 1 L duration of 8.5 months, mean total costs were $13,746 (all-cause) and $12,061 (PC-related) PPPM. The cost increase following 1 L therapy initiation was driven by higher PC-related outpatient and pharmacy costs. PC-related medical costs PPPM increased from $1,504 during baseline to $5,585 following 1 L mCRPC therapy initiation. LIMITATIONS All analyses were descriptive; statistical testing was not performed. CONCLUSION Incremental costs of progression to mCRPC are significant, with the majority of costs driven by higher PC-related costs. Using contemporary data, this study highlights the importance of utilizing effective therapies that slow progression and reduce healthcare resource demands despite the initial investment in treatment costs.
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Affiliation(s)
| | | | - Erik Muser
- Janssen Scientific Affairs, LLC., Horsham, PA, USA
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Kaye DR, Khilfeh I, Muser E, Morrison L, Kinkead F, Lefebvre P, Pilon D, George D. Characterizing the real-world economic burden of metastatic castration-sensitive prostate cancer in the United States. J Med Econ 2024; 27:381-391. [PMID: 38420699 DOI: 10.1080/13696998.2024.2323901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 02/23/2024] [Indexed: 03/02/2024]
Abstract
AIMS To describe healthcare resource utilization (HRU) and costs of patients with metastatic castration-sensitive prostate cancer (mCSPC). METHODS Linked data from Flatiron Metastatic PC Core Registry and Komodo's Healthcare Map were evaluated (01/2016-12/2021). Patients with chart-confirmed diagnoses for metastatic PC without confirmed castration resistance in Flatiron who initiated androgen deprivation therapy (ADT) monotherapy or advanced therapy for mCSPC in 2017 or later (index date) with a corresponding pharmacy or medical claim in Komodo Health were included. Advanced therapies considered were androgen-receptor signaling inhibitors, chemotherapies, estrogens, immunotherapies, poly ADP-ribose polymerase inhibitors, and radiopharmaceuticals. Patients with <12 months of continuous insurance eligibility before index were excluded. Per-patient-per-month (PPPM) all-cause and PC-related HRU and costs (medical and pharmacy; from a payer's perspective in 2022 $USD) were described in the 12-month baseline period and follow-up period (from the index date to castration resistance, end of continuous insurance eligibility, end of data availability, or death). RESULTS Of 871 patients included (mean age: 70.6 years), 52% initiated ADT monotherapy as their index treatment without documented advanced therapy use. During baseline, 31% of patients had a PC-related inpatient admission and 94% had a PC-related outpatient visit; mean all-cause costs were $2551 PPPM and PC-related costs were $839 PPPM with $787 PPPM attributable to medical costs. Patients had a mean follow-up of 15 months, during which 38% had a PC-related inpatient admission and 98% had a PC-related outpatient visit; mean all-cause costs were $5950 PPPM with PC-related total costs of $4363 PPPM, including medical costs of $2012 PPPM. LIMITATIONS All analyses were descriptive; statistical testing was not performed. Treatment effectiveness and clinical outcomes were not assessed. CONCLUSION This real-world study demonstrated a significant economic burden in mCSPC patients, and a propensity to use ADT monotherapy in clinical practice despite the availability and guideline recommendations of advanced life-prolonging therapies.
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Affiliation(s)
| | - Ibrahim Khilfeh
- Janssen Scientific Affairs, LLC, a Johnson & Johnson company, Horsham, PA, USA
| | - Erik Muser
- Janssen Scientific Affairs, LLC, a Johnson & Johnson company, Horsham, PA, USA
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Berger I, Spellman A, Golla V, Cerullo M, Zhang Y, Lipkin ME, Faerber GJ, Kaye DR, Scales CD. Rural For-Profit Hospitals Are Associated With Higher Commercial Prices for 3 Common Urological Procedures. Urol Pract 2023; 10:580-585. [PMID: 37647135 DOI: 10.1097/upj.0000000000000448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 08/03/2023] [Indexed: 09/01/2023]
Abstract
INTRODUCTION Rural patients lack access to urological services, and high local prices may dissuade underinsured patients from surgery. We sought to describe commercially insured prices for 3 urological procedures at rural vs metropolitan and for-profit vs nonprofit hospitals. METHODS A cross-sectional analysis of commercially insured prices from the Turquoise Health Transparency data set was performed for ureteroscopy with laser lithotripsy, transurethral resection of bladder tumor, and transurethral resection of prostate. Hospital characteristics were linked using the Centers for Medicare and Medicaid Services Healthcare Cost Reporting Information System. Linear modeling analyzed median hospital price and its association with hospital characteristics. RESULTS Overall, 1,532 hospitals reported urological prices in Turquoise. Median prices for each procedure were higher at rural for-profits (ureteroscopy $16,522, transurethral resection of bladder tumor $5,393, transurethral resection of prostate $9,999) vs rural nonprofits (ureteroscopy $4,512, transurethral resection of bladder tumor $2,788, transurethral resection of prostate $3,881) and metropolitan for-profits (ureteroscopy $5,411, transurethral resection of bladder tumor $3,420, transurethral resection of prostate $4,874). Rural for-profit status was independently associated with 160% higher price for ureteroscopy (relative cost ratio 2.60, P < .001), 50% higher for transurethral resection of bladder tumor (relative cost ratio 1.50, P = .002), and 113% higher for transurethral resection of prostate (relative cost ratio 2.13, P < .001). CONCLUSIONS Prices are higher for 3 common urological surgeries at rural for-profit hospitals. Differential pricing may contribute to disparities for underinsured rural residents who lack access to nonprofit facilities. Interventions that facilitate transportation and price shopping may improve access to affordable urological care.
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Affiliation(s)
- Ian Berger
- Division of Urology, Duke University Medical Center, Durham, North Carolina
| | | | - Vishnukamal Golla
- Division of Urology, Duke University Medical Center, Durham, North Carolina
- Durham Veterans Affairs Health Care System, Durham, North Carolina
- Duke University National Clinician Scholars Program, Durham, North Carolina
| | - Marcelo Cerullo
- Durham Veterans Affairs Health Care System, Durham, North Carolina
- Duke University National Clinician Scholars Program, Durham, North Carolina
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Yuqi Zhang
- Durham Veterans Affairs Health Care System, Durham, North Carolina
- Duke University National Clinician Scholars Program, Durham, North Carolina
- Department of Surgery, Yale New Haven Health System, New Haven, Connecticut
| | - Michael E Lipkin
- Division of Urology, Duke University Medical Center, Durham, North Carolina
| | - Gary J Faerber
- Division of Urology, Duke University Medical Center, Durham, North Carolina
| | - Deborah R Kaye
- Division of Urology, Duke University Medical Center, Durham, North Carolina
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Duke Cancer Institute, Duke University School of Medicine, Durham, North Carolina
- Margolis Center for Health Policy, Duke University, Durham, North Carolina
| | - Charles D Scales
- Division of Urology, Duke University Medical Center, Durham, North Carolina
- Duke University National Clinician Scholars Program, Durham, North Carolina
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
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Kaye DR. Drug costs: acquisition costs are critical but not the entire story of financial toxicity. BJU Int 2023; 132:115-116. [PMID: 37302985 PMCID: PMC11081428 DOI: 10.1111/bju.16092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Affiliation(s)
- Deborah R Kaye
- Department of Surgery, Duke University, Durham, NC, USA
- Duke-Margolis Center for Public Policy, Duke University, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
- Duke Cancer Institute, Durham, NC, USA
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Kaye DR, Lee HJ, Gordee A, George DJ, Ubel PA, Scales CD, Bundorf MK. Medication Payments by Insurers and Patients for the Treatment of Metastatic Castrate-Resistant Prostate Cancer. JCO Oncol Pract 2023; 19:e600-e617. [PMID: 36689695 PMCID: PMC10113111 DOI: 10.1200/op.22.00645] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 10/27/2022] [Accepted: 12/01/2022] [Indexed: 01/24/2023] Open
Abstract
PURPOSE The implications of high prices for cancer drugs on health care costs and patients' financial burdens are a growing concern. Patients with metastatic castrate-resistant prostate cancer (mCRPC) are often candidates for multiple first-line systemic therapies with similar impacts on life expectancy. However, little is known about the gross and out-of-pocket (OOP) payments associated with each of these drugs for patients with employer-sponsored health insurance. We therefore aimed to determine the gross and OOP payments of first-line drugs for mCRPC and how the payments vary across drugs. METHODS This retrospective cohort study included 4,298 patients with prostate cancer who initiated therapy with one of six drugs approved for first-line treatment of mCRPC between July 1, 2013, and June 30, 2019. We compared gross and OOP payments during the 6 months after initiation of treatment for mCRPC using private payer claims data across patients using different first-line drugs. RESULTS Gross payments varied across drugs. Over the 6 months after the index prescription, mean unadjusted gross drug payments were highest for patients receiving sipuleucel-T ($115,525 USD) and lowest for patients using docetaxel ($12,804 USD). OOP payments were lower than gross drug payments; mean 6-month OOP payments were highest for cabazitaxel ($1,044 USD) and lowest for docetaxel ($296 USD). There was a wide distribution of OOP payments within drug types. CONCLUSION Drugs for mCRPC are expensive with large differences in payments by drug type. OOP payments among patients with employer-sponsored health insurance are much lower than gross drug payments, and they vary both across and within first-line drug types, with some patients making very high OOP payments. Although lowering drug prices would reduce pharmaceutical spending for patients with mCRPC, decreasing patient financial burden requires understanding an individual patient's benefit design.
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Affiliation(s)
- Deborah R. Kaye
- Department of Surgery, Duke University, Durham, NC
- Duke-Margolis Center for Public Policy, Duke University, Durham, NC
- Duke Clinical Research Institute, Durham, NC
- Duke Cancer Institute, Durham, NC
| | - Hui-Jie Lee
- Department of Biostatistics, Duke University, Durham, NC
| | | | - Daniel J. George
- Department of Surgery, Duke University, Durham, NC
- Duke Cancer Institute, Durham, NC
- Department of Medicine, Duke University, Durham, NC
| | - Peter A. Ubel
- Department of Medicine, Duke University, Durham, NC
- Fuqua School of Business, Duke University, Durham, NC
- Sanford School of Public Policy, Duke University, Durham, NC
| | - Charles D. Scales
- Department of Surgery, Duke University, Durham, NC
- Duke Clinical Research Institute, Durham, NC
- Department of Population Health Sciences, Duke University, Durham, NC
| | - M. Kate Bundorf
- Duke-Margolis Center for Public Policy, Duke University, Durham, NC
- Sanford School of Public Policy, Duke University, Durham, NC
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Wilcox Vanden Berg RN, George AK, Kaye DR. Should Transperineal Prostate Biopsy Be the Standard of Care? Curr Urol Rep 2023; 24:135-142. [PMID: 36512186 DOI: 10.1007/s11934-022-01139-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/14/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW We reviewed the advantages and disadvantages of transperineal prostate biopsy (TP-bx) to evaluate its potential role as the standard of care for prostate biopsy. RECENT FINDINGS Studies have suggested no difference in prostate cancer (PCa) detection rate between TP-bx and transrectal biopsy (TR-bx) but have suggested potentially increased detection of anterior prostate tumors. Advances in anesthetic technique have obviated the need for sedation thus allowing TP-bx to become an office-based procedure, which in turn can decrease the overall cost of TP-bx. Furthermore, given the low rate of infectious complications after TP-bx, some have foregone peri-procedural antibiotics without a change in the rate of infectious complications. Recent procedural advances have made TP-bx a tolerable, office-based procedure. Given the similar diagnostic performance and the benefits for the patient and community, TP-bx should become the standard of care for prostate biopsy for most patients. Future efforts should address the barriers for more universal adoption.
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Affiliation(s)
| | - Arvin K George
- Department of Urology, University of Michigan, Ann Arbor, MI, USA.,Rogel Cancer Center, University of Michigan, Ann Arbor, MI, USA
| | - Deborah R Kaye
- Division of Urology, Department of Surgery, Duke University, Durham, NC, USA. .,Duke-Margolis Center for Public Policy, Duke University, Durham, NC, USA. .,Duke Clinical Research Institute, Durham, NC, USA. .,Duke Cancer Institute, Duke Cancer Center/Clinic 5-1, 20 Duke Medicine Circle Durham, Durham, NC, 27710, USA.
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Zhu A, Berends JE, Daignault-Newton S, Kaye DR, Parker C, IglayReger H, Morgan TM, Weizer AZ, Kaffenberger SD, Herrel LA, Hafez K, Skolarus TA, Montgomery JS. Use of a physical activity monitor to track perioperative activity of radical cystectomy patients our first glimpse at what our patients are doing before and after surgery. Urol Oncol 2023; 41:206.e11-206.e19. [PMID: 36842878 DOI: 10.1016/j.urolonc.2023.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 01/22/2023] [Accepted: 01/30/2023] [Indexed: 02/26/2023]
Abstract
PURPOSE To optimize recovery after radical cystectomy (RC), providers stress the importance of ambulation and adequate rest. However, little is known about the activity and sleep habits of patients undergoing RC. Therefore, we utilized a wearable physical activity monitor (PAM) in the perioperative period to provide the first objective data on physical activity and sleep habits for RC patients. MATERIALS AND METHODS We prospectively identified patients ≥60 years old with planned RC. Participants completed a 4-week prehabilitation exercise program prior to surgery. They wore a PAM for 7-day intervals: at baseline, after prehabilitation, at postoperative day (POD) 30 and POD90. We tracked physical activity via metabolic equivalents (METs). METs were categorized by intensity: light (MET 1.5-<3), moderate (MET 3-<6), and vigorous (MET ≥6). We calculated daily step totals. We tracked hours slept and number of sleep awakenings. We correlated activity and sleep with self-reported quality of life (QOL). RESULTS Forty-two patients completed prehabilitation and RC. Moderate intensity exercise decreased at POD30 (61 minutes/d at baseline, 30 minutes/d at POD30, P = 0.005). Physical activity did not significantly differ for light or vigorous activity at any timepoint. RC did not significantly affect sleep. Sleep and physical activity were associated with mental and physical QOL, respectively. CONCLUSIONS This is the first study utilizing patient-worn monitors in RC to track physical activity and sleep. This study gives patients and providers a better understanding of postcystectomy recovery expectations. With these results in mind, interventions may be implemented to optimize activity and sleep in the perioperative period.
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Affiliation(s)
- Alex Zhu
- Department of Urology, Michigan Medicine, Ann Arbor, MI
| | | | | | - Deborah R Kaye
- Division of Urology, Department of Surgery, Duke University, Durham, NC
| | - Chrissy Parker
- Department of Physical Medicine and Rehabilitation, Michigan Medicine, Ann Arbor, MI
| | - Heidi IglayReger
- Department of Physical Medicine and Rehabilitation, Michigan Medicine, Ann Arbor, MI
| | - Todd M Morgan
- Department of Urology, Michigan Medicine, Ann Arbor, MI
| | - Alon Z Weizer
- Department of Urology, Michigan Medicine, Ann Arbor, MI
| | | | | | - Khaled Hafez
- Department of Urology, Michigan Medicine, Ann Arbor, MI
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Dzimitrowicz HE, Wilson LE, Jackson BE, Spees LP, Baggett CD, Greiner MA, Kaye DR, Zhang T, George D, Scales CD, Pritchard JE, Leapman MS, Gross CP, Dinan MA, Wheeler SB. End-of-Life Care for Patients With Metastatic Renal Cell Carcinoma in the Era of Oral Anticancer Therapy. JCO Oncol Pract 2023; 19:e213-e227. [PMID: 36413741 PMCID: PMC9970274 DOI: 10.1200/op.22.00401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 08/31/2022] [Accepted: 10/06/2022] [Indexed: 11/23/2022] Open
Abstract
PURPOSE New therapies including oral anticancer agents (OAAs) have improved outcomes for patients with metastatic renal cell carcinoma (mRCC). However, little is known about the quality of end-of-life (EOL) care and systemic therapy use at EOL in patients receiving OAAs or with mRCC. METHODS We retrospectively analyzed EOL care for decedents with mRCC in two parallel cohorts: (1) patients (RCC diagnosed 2004-2015) from the University of North Carolina's Cancer Information and Population Health Resource (CIPHR) and (2) patients (diagnosed 2007-2015) from SEER-Medicare. We assessed hospice use in the last 30 days of life and existing measures of poor-quality EOL care: systemic therapy, hospital admission, intensive care unit admission, and > 1 ED visit in the last 30 days of life; hospice initiation in the last 3 days of life; and in-hospital death. Associations between OAA use, patient and provider characteristics, and EOL care were examined using multivariable logistic regression. RESULTS We identified 410 decedents in the CIPHR cohort (53.4% received OAA) and 1,508 in SEER-Medicare (43.5% received OAA). Prior OAA use was associated with increased systemic therapy in the last 30 days of life in both cohorts (CIPHR: 26.5% v 11.0%; P < .001; SEER-Medicare: 23.4% v 11.7%; P < .001), increased in-hospital death in CIPHR, and increased hospice in the last 30 days in SEER-Medicare. Older patients were less likely to receive systemic therapy or be admitted in the last 30 days or die in hospital. CONCLUSION Patients with mRCC who received OAAs and younger patients experienced more aggressive EOL care, suggesting opportunities to optimize high-quality EOL care in these groups.
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Affiliation(s)
| | - Lauren E. Wilson
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | | | - Lisa P. Spees
- Lineberger Comprehensive Cancer Center, UNC-CH, Chapel Hill, NC
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill (UNC-CH), Chapel Hill, NC
| | - Christopher D. Baggett
- Lineberger Comprehensive Cancer Center, UNC-CH, Chapel Hill, NC
- Department of Epidemiology, Gillings School of Global Public Health, UNC-CH, Chapel Hill, NC
| | - Melissa A. Greiner
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | - Deborah R. Kaye
- Department of Surgery (Urology), Duke University School of Medicine, Durham, NC
- Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC
| | - Tian Zhang
- Division of Hematology and Oncology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
- Division of Medical Oncology, Department of Medicine, Duke University, Durham, NC
| | - Daniel George
- Department of Medicine, Duke University School of Medicine, Durham, NC
- Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC
| | - Charles D. Scales
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
- Department of Surgery (Urology), Duke University School of Medicine, Durham, NC
| | - Jessica E. Pritchard
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | - Michael S. Leapman
- Department of Urology, Yale School of Medicine, New Haven, CT
- Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, CT
| | - Cary P. Gross
- Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, CT
- Department of Medicine, Yale School of Medicine, New Haven, CT
| | - Michaela A. Dinan
- Department of Medicine, Yale School of Medicine, New Haven, CT
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT
| | - Stephanie B. Wheeler
- Lineberger Comprehensive Cancer Center, UNC-CH, Chapel Hill, NC
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill (UNC-CH), Chapel Hill, NC
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Berger I, Golla V, Cerullo M, Zhang Y, Lipkin ME, Faerber GJ, Scales CD, Kaye DR. Association of Rural Hospital For-Profit Status With Higher Publicly Reported Prices for the Components of Inpatient Hematuria Evaluation Among Commercially Insured Patients. Urology Practice 2023; 10:132-137. [PMID: 37103403 DOI: 10.1097/upj.0000000000000374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
INTRODUCTION Rural patients have limited access to urological care and are vulnerable to high local prices. Little is known about price variation for urological conditions. We aimed to compare reported commercial prices for the components of inpatient hematuria evaluation between for-profit vs not-for-profit and rural vs metropolitan hospitals. METHODS We abstracted commercial prices for the components of intermediate- and high-risk hematuria evaluation from a price transparency data set. We compared hospital characteristics between those that do and do not report prices for a hematuria evaluation using the Centers for Medicare and Medicaid Services Healthcare Cost Reporting Information System. Generalized linear modelling evaluated the association between hospital ownership and rural/metropolitan status with prices of intermediate- and high-risk evaluations. RESULTS Of all hospitals, 17% of for-profits and 22% of not-for-profits report prices for hematuria evaluation. For intermediate-risk, median price at rural for-profit hospitals was $6,393 (interquartile range [IQR] $2,357-$9,295) compared to $1,482 (IQR $906-$2,348) at rural not-for-profits and $2,645 (IQR $1,491-$4,863) at metropolitan for-profits. For high-risk, rural for-profit hospitals' median price was $11,151 (IQR $5,826-$14,366) vs $3,431 (IQR $2,474-$5,156) at rural not-for-profits and $4,188 (IQR $1,973-$8,663) at metropolitan for-profits. Rural for-profit status was associated with an additional higher price for intermediate- (relative cost ratio 1.62, 95% CI 1.16-2.28, P = .005) and high-risk evaluations (relative cost ratio 1.50, 95% CI 1.15-1.97, P = .003). CONCLUSIONS Rural for-profit hospitals report high prices for components of inpatient hematuria evaluation. Patients should be aware of prices at these facilities. These differences may dissuade patients from undergoing evaluation and lead to disparities.
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Affiliation(s)
- Ian Berger
- Division of Urology, Duke University School of Medicine, Durham, North Carolina
| | - Vishnukamal Golla
- Division of Urology, Duke University School of Medicine, Durham, North Carolina
- Durham Veterans Affairs Health Care System
- Duke University National Clinician Scholars Program
| | - Marcelo Cerullo
- Durham Veterans Affairs Health Care System
- Duke University National Clinician Scholars Program
- Department of Surgery, Duke University School of Medicine
| | - Yuqi Zhang
- Durham Veterans Affairs Health Care System
- Duke University National Clinician Scholars Program
- Department of Surgery, Yale University School of Medicine
| | - Michael E. Lipkin
- Division of Urology, Duke University School of Medicine, Durham, North Carolina
| | - Gary J. Faerber
- Division of Urology, Duke University School of Medicine, Durham, North Carolina
| | - Charles D. Scales
- Division of Urology, Duke University School of Medicine, Durham, North Carolina
- Duke University National Clinician Scholars Program
- Duke Clinical Research Institute, Duke University School of Medicine
| | - Deborah R. Kaye
- Division of Urology, Duke University School of Medicine, Durham, North Carolina
- Duke Clinical Research Institute, Duke University School of Medicine
- Duke Cancer Institute, Duke University School of Medicine
- Margolis Center for Health Policy, Duke University
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10
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Spees LP, Dinan MA, Jackson BE, Baggett CD, Wilson LE, Greiner MA, Kaye DR, Zhang T, George DJ, Scales CD, Pritchard JE, Leapman M, Gross CP, Wheeler SB. Patient- And Provider-Level Predictors of Survival Among Patients With Metastatic Renal Cell Carcinoma Initiating Oral Anticancer Agents. Clin Genitourin Cancer 2022; 20:e396-e405. [PMID: 35595633 PMCID: PMC9529768 DOI: 10.1016/j.clgc.2022.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 04/14/2022] [Accepted: 04/18/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE In an era of rapid expansion of FDA approvals for oral anticancer agents (OAAs), it is important to understand the factors associated with survival among real-world populations, which include groups not well-represented in pivotal clinical trials of OAAs, such as the elderly, racial minorities, and medically complex patients. Our objective was to evaluate patient- and provider-level characteristics' associations with mortality among a multi-payer cohort of metastatic renal cell carcinoma (mRCC) patients who initiated OAAs. METHODS This retrospective cohort study was conducted using data from the North Carolina state cancer registry linked to multi-payer claims data for the years 2004 to 2015. Provider data were obtained from North Carolina Health Professions Data System and the National Plan & Provider Enumeration System. Included patients were individuals with mRCC who initiated an OAA and survived ≥90 days after beginning treatment. We estimated hazard ratios (HR) and corresponding 95% confidence limits (CL) using Cox hazard models for associations between patient demographics, patient clinical characteristics, provider-level factors, and 2-year all-cause mortality. RESULTS The cohort included 207 patients with mRCC who received OAAs. In multivariable models, clinical variables such as frailty (HR: 1.36, 95% CL: 1.11-1.67) and de novo metastatic diagnosis (HR: 2.63, 95%CL: 1.67-4.16) were associated with higher all-cause mortality. Additionally, patients solely on Medicare had higher adjusted all-cause mortality compared with patients with any private insurance (HR: 2.35, 95% CL: 1.32-4.18). No provider-level covariates investigated were associated with all-cause mortality. CONCLUSIONS Within a real-world population of mRCC patients taking OAAs, survival differed based on patient characteristics. In an era of rapid expansion of FDA approvals for OAAs, these real-world data underscore the continued importance of access to high-quality care, particularly for medically complex patients with limited resources.
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Affiliation(s)
- Lisa P Spees
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill (UNC-CH), Chapel Hill, NC; Lineberger Comprehensive Cancer Center (LCCC), UNC-CH, Chapel Hill, NC, USA.
| | - Michaela A Dinan
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, CT, USA; Department of Chronic Disease Epidemiology, Yale School of Medicine, Yale School of Public Health, New Haven, CT, USA
| | - Bradford E Jackson
- Lineberger Comprehensive Cancer Center (LCCC), UNC-CH, Chapel Hill, NC, USA
| | - Christopher D Baggett
- Lineberger Comprehensive Cancer Center (LCCC), UNC-CH, Chapel Hill, NC, USA; Department of Epidemiology, Gillings School of Global Public Health, UNC-CH, Chapel Hill, NC, USA
| | - Lauren E Wilson
- Department of Population Health Sciences, Duke University School of Medicine (DUSM), Durham, NC, USA
| | - Melissa A Greiner
- Department of Population Health Sciences, Duke University School of Medicine (DUSM), Durham, NC, USA
| | - Deborah R Kaye
- Duke Cancer Institute (DCI) Center for Prostate and Urologic Cancers, Durham, NC, USA; Department of Surgery (Urology), DUSM, Durham, NC, USA
| | - Tian Zhang
- Department of Medicine, DUSM, Durham, NC, USA; Department of Surgery (Urology), DUSM, Durham, NC, USA
| | - Daniel J George
- Duke Cancer Institute (DCI) Center for Prostate and Urologic Cancers, Durham, NC, USA; Department of Medicine, DUSM, Durham, NC, USA
| | - Charles D Scales
- Department of Population Health Sciences, Duke University School of Medicine (DUSM), Durham, NC, USA; Department of Surgery (Urology), DUSM, Durham, NC, USA
| | - Jessica E Pritchard
- Department of Population Health Sciences, Duke University School of Medicine (DUSM), Durham, NC, USA
| | - Michael Leapman
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, CT, USA; Department of Urology, Yale School of Medicine, New Haven, CT, USA
| | - Cary P Gross
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, CT, USA; Department of Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Stephanie B Wheeler
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill (UNC-CH), Chapel Hill, NC; Lineberger Comprehensive Cancer Center (LCCC), UNC-CH, Chapel Hill, NC, USA; Duke Cancer Institute (DCI), DUSM, Durham, NC, USA
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11
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Pritchard JE, Wilson LE, Miller SM, Greiner MA, Cohen HJ, Kaye DR, Zhang T, Dinan MA. Association between cognitive impairment and oral anticancer agent use in older patients with metastatic renal cell carcinoma. J Am Geriatr Soc 2022; 70:2330-2343. [PMID: 35499667 PMCID: PMC9378524 DOI: 10.1111/jgs.17826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 03/14/2022] [Accepted: 03/28/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND Kidney cancer is the fastest-growing cancer diagnosis in the developed world. About 16% of new cases are stage IV, which has a low five-year survival rate. Many patients with metastatic renal cell carcinoma (mRCC) are older and may have mild cognitive impairment or dementia (MCI/D). Given prior reports of patients with dementia initiating less cancer therapy and the importance of oral anticancer agents (OAAs) in mRCC treatment, we investigated the prevalence of preexisting MCI/D in patients with mRCC and their OAA use. METHODS SEER-Medicare patients were analyzed who were ≥65 years, diagnosed with mRCC between 2007 and 2015, and had Medicare part D coverage. Patterns and predictors of (a) OAA utilization within the 12 months following mRCC diagnosis and (b) adherence (percent of days covered [PDC] ≥ 80%) during the first 90 days following treatment initiation were assessed. RESULTS Of the 2792 eligible patients, 268 had preexisting MCI/D, and 907 initiated OAA treatment within 12 months of mRCC diagnosis. Patients with preexisting MCI/D were less likely to begin an OAA than those without MCI/D (fully-adjusted HR 0.53, 95% CI 0.38-0.76). Among OAA initiators, a preexisting MCI/D diagnosis did not alter the likelihood that a person would be adherent (adjusted RR 0.84, 95% CI 0.55-1.28). CONCLUSIONS Patients with preexisting MCI/D were half as likely to start an OAA during the year following mRCC diagnosis than patients without comorbid MCI/D. The 90-day adherence of OAA initiators was not significantly different between those with and without preexisting MCI/D. In light of this, clinicians should assess mRCC patients for cognitive impairment and take steps to optimize OAA utilization by those with MCI/D.
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Affiliation(s)
| | | | - Samuel M. Miller
- National Clinician Scholars Program, Yale University
- Department of Surgery, Yale University
| | | | - Harvey Jay Cohen
- Center for the Study of Aging and Human Development, Duke University
| | | | - Tian Zhang
- Division of Medical Oncology, Department of Medicine, Duke University
- Division of Hematology and Oncology, Department of Internal Medicine, UT Southwestern Medical Center
| | - Michaela A. Dinan
- Department of Chronic Disease Epidemiology, Yale School of Public Health
- Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center
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12
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Miller SM, Wilson LE, Greiner MA, Pritchard JE, Zhang T, Kaye DR, Cohen HJ, Becher RD, Maerz LL, Dinan MA. Evaluation of mild cognitive impairment and dementia in patients with metastatic renal cell carcinoma. J Geriatr Oncol 2022; 13:635-643. [PMID: 34996724 PMCID: PMC9232862 DOI: 10.1016/j.jgo.2021.12.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 12/07/2021] [Accepted: 12/14/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND Dementia and cancer are both more common in adults as they age. As new cancer treatments become more popular, it is important to consider how these treatments might affect older patients. This study evaluates metastatic renal cell carcinoma (mRCC) as a risk factor for older adults developing mild cognitive impairment or dementia (MCI/D) and the impact of mRCC-directed therapies on the development of MCI/D. METHODS We identified patients diagnosed with mRCC in a Surveillance, Epidemiology, and End Results (SEER)-Medicare dataset from 2007 to 2015 and matched them to non-cancer controls. Exclusion criteria included age < 65 years at mRCC diagnosis and diagnosis of MCI/D within the year preceding mRCC diagnosis. The main outcome was time to incident MCI/D within one year of mRCC diagnosis for cases or cohort entry for non-cancer controls. Cox proportional hazards models were used to measure associations between mRCC and incident MCI/D as well as associations of oral anticancer agent (OAA) use with MCI/D development within the mRCC group. RESULTS Patients with mRCC (n = 2533) were matched to non-cancer controls (n = 7027). mRCC (hazard ratio [HR] 8.52, p < .001), being older (HR 1.05 per 1-year age increase, p < .001), and identifying as Black (HR 1.92, p = .047) were predictive of developing MCI/D. In addition, neither those initiating treatment with OAAs nor those who underwent nephrectomy were more likely to develop MCI/D. CONCLUSIONS Patients with mRCC were more likely to develop MCI/D than those without mRCC. The medical and surgical therapies evaluated were not associated with increased incidence of MCI/D. The increased incidence of MCI/D in older adults with mRCC may be the result of the pathology itself or risk factors common to the two disease processes.
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Affiliation(s)
- Samuel M Miller
- National Clinician Scholars Program, Yale University, USA; Department of Surgery, Yale University, USA.
| | - Lauren E Wilson
- Department of Population Health Sciences, Duke University, USA
| | | | | | - Tian Zhang
- Division of Hematology and Oncology, Department of Internal Medicine, UT Southwestern Medical Center, USA
| | - Deborah R Kaye
- Department of Surgery, Division of Urology, Duke University, USA
| | - Harvey Jay Cohen
- Center for the Study of Aging and Human Development, Duke University, USA
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13
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Kaye DR, Wilson LE, Greiner MA, Spees LP, Pritchard JE, Zhang T, Pollack CE, George D, Scales CD, Baggett CD, Gross CP, Leapman MS, Wheeler SB, Dinan MA. Patient, provider, and hospital factors associated with oral anti-neoplastic agent initiation and adherence in older patients with metastatic renal cell carcinoma. J Geriatr Oncol 2022; 13:614-623. [PMID: 35125336 PMCID: PMC9232903 DOI: 10.1016/j.jgo.2022.01.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 12/16/2021] [Accepted: 01/13/2022] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Oral anti-neoplastic agents (OAAs) for metastatic renal cell carcinoma (mRCC) are associated with increased cancer-specific survival. However, racial disparities in survival persist and older adults have the lowest rates of cancer-specific survival. Research from other cancers demonstrates specialty access is associated with high-quality cancer care, but older adults receive cancer treatment less often than younger adults. We therefore examined whether patient, provider, and hospital characteristics were associated with OAA initiation, adherence, and cancer-specific survival after initiation and whether race, ethnicity, and/or age was associated with an increased likelihood of seeing a medical oncologist for diagnosis of mRCC. PATIENTS AND METHODS We used Surveillance, Epidemiology, and End Results (SEER)Medicare data to identify patients ≥65 years of age who were diagnosed with mRCC from 2007 to 2015 and enrolled in Medicare Part D. Insurance claims were used to identify receipt of OAAs within twelve months of metastatic diagnosis, calculate proportion of days covered, and to identify the primary cancer provider and hospital. We examined provider and hospital characteristics associated with OAA initiation, adherence, and all-cause mortality after OAA initiation. RESULTS We identified 2792 patients who met inclusion criteria. Increased OAA initiation was associated with access to a medical oncologist. Patients were less likely to begin OAA treatment if their primary oncologic provider was a urologist (hazard ratio [HR] 0.62; 95% confidence interval [CI] 0.49-0.77). Provider/hospital characteristics were not associated with differences in OAA adherence or mortality. Patients who started sorafenib (odds ratio [OR] 0.50; 95% CI 0.29-0.86), were older (aged >81 OR 0.56; 95% CI 0.34-0.92), and those living in high poverty ZIP codes (OR 0.48; 95% CI 0.29-0.80) were less likely to adhere to OAA treatment. Furthermore, provider characteristics did not account for differences in mortality once an OAA was initiated. Last, only age > 81 years was statistically and clinically associated with a decreased relative risk of seeing a medical oncologist (risk ratio [RR] 0.87; CI 0.82-0.92). CONCLUSION Provider/hospital factors, specifically, being seen by a medical oncologist for mRCC diagnosis, are associated with OAA initiation. Older patients were less likely to see a medical oncologist; however, race and/or ethnicity was not associated with differences in seeing a medical oncologist. Patient factors are more critical to OAA adherence and mortality after OAA initiation than provider/hospital factors.
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Affiliation(s)
- Deborah R Kaye
- Department of Surgery (Urology), Duke University School of Medicine, Durham, NC, United States of America; Duke-Margolis Policy Center, Duke University School of Medicine, Durham, NC, United States of America; Duke Cancer Institute, Durham, NC, United States of America
| | - Lauren E Wilson
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States of America
| | - Melissa A Greiner
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States of America
| | - Lisa P Spees
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill (UNC-CH), Chapel Hill, NC, United States of America; Lineberger Comprehensive Cancer Center, UNC-CH, Chapel Hill, NC, United States of America
| | - Jessica E Pritchard
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States of America
| | - Tian Zhang
- Duke Cancer Institute, Durham, NC, United States of America; Department of Medicine, Duke University School of Medicine, Durham, NC, United States of America
| | - Craig E Pollack
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Daniel George
- Duke Cancer Institute, Durham, NC, United States of America; Department of Medicine, Duke University School of Medicine, Durham, NC, United States of America
| | - Charles D Scales
- Department of Surgery (Urology), Duke University School of Medicine, Durham, NC, United States of America; Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States of America
| | - Chris D Baggett
- Lineberger Comprehensive Cancer Center, UNC-CH, Chapel Hill, NC, United States of America; Department of Epidemiology, Gillings School of Global Public Health, UNC-CH, Chapel Hill, NC, United States of America
| | - Cary P Gross
- Department of Medicine, Yale School of Medicine, New Haven, CT, United States of America; Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, CT, United States of America
| | - Michael S Leapman
- Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, CT, United States of America; Department of Urology, Yale School of Medicine, New Haven, CT, United States of America
| | - Stephanie B Wheeler
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill (UNC-CH), Chapel Hill, NC, United States of America; Lineberger Comprehensive Cancer Center, UNC-CH, Chapel Hill, NC, United States of America
| | - Michaela A Dinan
- Department of Urology, Yale School of Medicine, New Haven, CT, United States of America.
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14
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Golla V, Allen Lapointe NM, Silberberg M, Wang V, Lentz TA, Kaye DR, Sorenson C, Saunders R, Kaufman BG. Improving health equity for older people with serious illness through value based payment reform. J Am Geriatr Soc 2022; 70:2180-2185. [PMID: 35474173 DOI: 10.1111/jgs.17815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 04/11/2022] [Accepted: 04/13/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Vishnukamal Golla
- National Clinician Scholars Program, Duke University, Durham, North Carolina, USA.,Department of Surgery, Division of Urology, Duke University School of Medicine, Durham, North Carolina, USA.,Health Services Research and Development, Durham VA Healthcare System, Durham, North Carolina, USA
| | - Nancy M Allen Lapointe
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA.,Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Mina Silberberg
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA.,Department of Family Medicine and Community Health, Duke University School of Medicine, Durham, North Carolina, USA
| | - Virginia Wang
- Health Services Research and Development, Durham VA Healthcare System, Durham, North Carolina, USA.,Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA.,Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.,Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Trevor A Lentz
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA.,Department of Orthopedic Surgery, Duke University School of Medicine, Durham, North Carolina, USA.,Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Deborah R Kaye
- Department of Surgery, Division of Urology, Duke University School of Medicine, Durham, North Carolina, USA.,Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA.,Duke Clinical Research Institute, Durham, North Carolina, USA.,Duke Cancer Institute, Durham, North Carolina, USA
| | - Corinna Sorenson
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA.,Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA.,Duke Clinical Research Institute, Durham, North Carolina, USA.,Sanford School of Public Policy, Duke University, Durham, North Carolina, USA
| | - Robert Saunders
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA
| | - Brystana G Kaufman
- Health Services Research and Development, Durham VA Healthcare System, Durham, North Carolina, USA.,Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA.,Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
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15
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Golla V, Kaye DR. The Impact of Health Delivery Integration on Cancer Outcomes. Surg Oncol Clin N Am 2021; 31:91-108. [PMID: 34776068 DOI: 10.1016/j.soc.2021.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Although integrated health care has largely been associated with increases in prices and static or decreased quality across many disease states, it has shown some successes in improving cancer care. However, its impact is largely equivocal, making consensus statements difficult. Critically, integration does not necessarily translate to clinical coordination, which might be the true driver behind the success of integrated health care delivery. Moving forward, it is important to establish payment models that support clinical care coordination. Shifting from a fragmented health system to a coordinated one may improve evidence-based cancer care, outcomes, and value for patients.
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Affiliation(s)
- Vishnukamal Golla
- Duke National Clinician Scholars Program, 200 Morris St, Suite 3400, DUMC Box 104427, Durham, NC 27701, USA; Department of Surgery, Division of Urology, Duke University Medical Center, Durham, NC, USA; Duke Cancer Institute, Durham, NC, USA; Duke-Margolis Policy Center; Durham Veterans Affairs Health Care System, Durham, NC, USA.
| | - Deborah R Kaye
- Department of Surgery, Division of Urology, Duke University Medical Center, Durham, NC, USA; Duke Cancer Institute, Durham, NC, USA; Duke-Margolis Policy Center
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16
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Spees LP, Wheeler SB, Jackson BE, Baggett CD, Wilson LE, Greiner MA, Kaye DR, Zhang T, George D, Scales CD, Pritchard JE, Leapman M, Gross CP, Dinan MA. Provider- and patient-level predictors of oral anticancer agent initiation and adherence in patients with metastatic renal cell carcinoma. Cancer Med 2021; 10:6653-6665. [PMID: 34480518 PMCID: PMC8495289 DOI: 10.1002/cam4.4201] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 07/28/2021] [Accepted: 07/29/2021] [Indexed: 01/25/2023] Open
Abstract
Background Improving oral anticancer agent (OAA) initiation and adherence is the important quality‐of‐care issues, particularly since one fourth of anticancer agents being developed will be administered orally. Our objective was to identify provider‐ and patient‐level characteristics associated with OAA initiation and adherence among individuals with metastatic renal cell carcinoma (mRCC). Methods We used state cancer registry data linked to multi‐payer claims data to identify patients with mRCC diagnosed in 2004–2015. Provider data were obtained from North Carolina Health Professions Data System and the National Plan & Provider Enumeration System. We estimated risk ratios (RRs) and corresponding 95% confidence limits (CLs) using modified Poisson regression to evaluate factors associated with OAA initiation and adherence. Results Among the 207 (out of 687) patients who initiated an OAA following mRCC diagnosis and survived 90 days, median proportion of days covered was 0.91. Patients with a modal provider specializing in hematology/medical oncology were much more likely to initiate OAAs than those seen by other specialties. Additionally, patients with a female provider were more likely to initiate OAAs than those with a male provider. Compared to patients treated by providers practicing in both urban and rural areas, patients with providers practicing solely in urban areas were more likely to initiate OAAs, after controlling for patient‐level factors (RR = 1.37; 95% CL: 1.09–1.73). Medicare patients were less likely to be adherent than those with private insurance (RR = 0.61; 95% CL: 0.42–0.87). Conclusions Our results suggest that provider‐ and patient‐level factors influence OAA initiation in patients with mRCC but only insurance type was associated with adherence.
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Affiliation(s)
- Lisa P Spees
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill (UNC-CH), Chapel Hill, North Carolina, USA.,Lineberger Comprehensive Cancer Center (LCCC), UNC-CH, Chapel Hill, North Carolina, USA
| | - Stephanie B Wheeler
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill (UNC-CH), Chapel Hill, North Carolina, USA.,Lineberger Comprehensive Cancer Center (LCCC), UNC-CH, Chapel Hill, North Carolina, USA
| | - Bradford E Jackson
- Lineberger Comprehensive Cancer Center (LCCC), UNC-CH, Chapel Hill, North Carolina, USA
| | - Christopher D Baggett
- Lineberger Comprehensive Cancer Center (LCCC), UNC-CH, Chapel Hill, North Carolina, USA.,Department of Epidemiology, Gillings School of Global Public Health, UNC-CH, Chapel Hill, North Carolina, USA
| | - Lauren E Wilson
- Department of Population Health Sciences, Duke University School of Medicine (DUSM), Durham, North Carolina, USA
| | - Melissa A Greiner
- Department of Population Health Sciences, Duke University School of Medicine (DUSM), Durham, North Carolina, USA
| | - Deborah R Kaye
- Duke Cancer Institute (DCI) Center for Prostate and Urologic Cancers, Durham, North Carolina, USA.,Department of Medicine, DUSM, Durham, North Carolina, USA
| | - Tian Zhang
- Duke Cancer Institute (DCI) Center for Prostate and Urologic Cancers, Durham, North Carolina, USA.,Department of Medicine, DUSM, Durham, North Carolina, USA.,Department of Surgery (Urology), DUSM, Durham, North Carolina, USA
| | - Daniel George
- Duke Cancer Institute (DCI) Center for Prostate and Urologic Cancers, Durham, North Carolina, USA.,Department of Medicine, DUSM, Durham, North Carolina, USA
| | - Charles D Scales
- Department of Population Health Sciences, Duke University School of Medicine (DUSM), Durham, North Carolina, USA.,Department of Surgery (Urology), DUSM, Durham, North Carolina, USA
| | - Jessica E Pritchard
- Department of Population Health Sciences, Duke University School of Medicine (DUSM), Durham, North Carolina, USA
| | - Michael Leapman
- Department of Urology, Yale School of Medicine, New Haven, Connecticut, USA.,Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, Connecticut, USA
| | - Cary P Gross
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, Connecticut, USA.,Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Michaela A Dinan
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, Connecticut, USA.,Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut, USA
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17
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Sessine MS, Das S, Park B, Salami SS, Kaffenberger SD, Kasputis A, Solorzano M, Luke M, Vince RA, Kaye DR, Borza T, Stoffel EM, Cobain E, Merajver SD, Jacobs MF, Milliron KJ, Caba L, van Neste L, Mondul AM, Morgan TM. Initial Findings from a High Genetic Risk Prostate Cancer Clinic. Urology 2021; 156:96-103. [PMID: 34280438 DOI: 10.1016/j.urology.2021.05.078] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 05/06/2021] [Accepted: 05/11/2021] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To improve prostate cancer screening for high-risk men, we developed an early detection clinic for patients at high genetic risk of developing prostate cancer. Despite the rapidly growing understanding of germline variants in driving aggressive prostate cancer and the increased availability of genetic testing, there is little evidence surrounding how best to screen these men. METHODS We are reporting on the first 45 patients enrolled, men between the ages of 35-75, primarily with known pathogenic germline variants in prostate cancer susceptibility genes. Screening consists of an intake lifestyle survey, PSA, DRE, and SelectMDx urine assay. A biopsy was recommended for any of the following indications: 1) abnormal DRE, 2) PSA above threshold, or 3) SelectMDx above threshold. The primary outcomes were number needed to screen, and number needed to biopsy to diagnose a patient with prostate cancer. RESULTS Patients enrolled in the clinic included those with BRCA1 (n=7), BRCA2 (n=16), Lynch Syndrome (n=6), and CHEK2 (n = 4) known pathogenic germline variants. The median age and PSA were 58 (range 35-71) and 1.4 ng/ml (range 0.1-11.4 ng/ml), respectively. 12 patients underwent a prostate needle biopsy and there were 4positive biopsies for prostate cancer. CONCLUSION These early data support the feasibility of opening a dedicated clinic for men at high genetic risk of prostate cancer. This early report on the initial enrollment of our long-term study will help optimize early detection protocols and provide evidence for personalized prostate cancer screening in men with key pathogenic germline variants.
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Affiliation(s)
| | - Sanjay Das
- Department of Urology, Michigan Medicine
| | - Bumsoo Park
- Department of Urology, Michigan Medicine; Department of Family Medicine, Michigan Medicine
| | | | | | | | | | | | | | | | - Tudor Borza
- Department of Urology, University of Wisconsin School of Medicine and Public Health; Division of Urology, William S Middleton Memorial Veterans Hospital
| | | | - Erin Cobain
- Medical Genetics, Rogel Cancer Center, Michigan Medicine
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18
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Grimberg DC, Tejwani R, Allkanjari A, Forrester MT, Kraft BD, Kaye DR. Ischemic priapism due to coagulopathy of severe COVID-19 infection. Journal of Clinical Urology 2021. [DOI: 10.1177/20514158211025914] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Initially thought to be a primarily respiratory disease process, the hypercoagulable state associated with COVID-19 has been associated with myriad clinical sequelae. We report a case of stuttering ischemic priapism associated with COVID-19, and describe a management approach to achieve detumescence in patients undergoing ventilatory proning limiting penile access. Level of evidence: Not applicable for this single center case report.
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Affiliation(s)
- Dominic C Grimberg
- Division of Urology, Department of Surgery, Duke University Medical Center, Durham NC, USA
| | - Rohit Tejwani
- Division of Urology, Department of Surgery, Duke University Medical Center, Durham NC, USA
| | - Armand Allkanjari
- Division of Urology, Department of Surgery, Duke University Medical Center, Durham NC, USA
| | - Michael T Forrester
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University Medical Center, Durham NC, USA
| | - Bryan D Kraft
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University Medical Center, Durham NC, USA
| | - Deborah R Kaye
- Division of Urology, Department of Surgery, Duke University Medical Center, Durham NC, USA
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19
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Wheeler SB, Spees LP, Jackson BE, Baggett CD, Wilson LE, Greiner MA, Kaye DR, Zhang T, George D, Scales CD, Pritchard JE, Dinan MA. Patterns and Predictors of Oral Anticancer Agent Use in Diverse Patients With Metastatic Renal Cell Carcinoma. JCO Oncol Pract 2021; 17:e1895-e1904. [PMID: 34138665 DOI: 10.1200/op.20.01082] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Availability of targeted oral anticancer agents (OAAs) has transformed care for patients with metastatic renal cell carcinoma (mRCC). Our objective was to identify patterns and predictors of OAA use within 12 months after mRCC was detected to understand real-world adoption of OAAs. METHODS We used a novel, North Carolina cancer registry-linked multipayer claims data resource to examine patterns of use of five oral therapies among patients with mRCC diagnosed in 2006-2015, with claims through 2016. Patients were required to have 12 months of continuous enrollment before metastatic index date. Log-Poisson models estimated unadjusted and adjusted risk ratios (RRs) for associations between patient characteristics and OAA use. In sensitivity analyses, we used a competing risk framework to estimate adjusted risk differences in OAA use. RESULTS Our population-based study of 713 patients demonstrated low (37%) OAA use during the first year after metastatic index date among both publicly and privately insured patients, with shifting patterns of use consistent with regulatory approvals over time. Compared with patients age 18-49 years, patients age 70-74 years were half likely to use OAAs (95% confidence limit [CL], 0.34 to 0.78) and patients age 80+ years were 71% less likely to use OAAs (95% CL, 0.17 to 0.50). Patients with two comorbidities (RR, 0.73; 95% CL, 0.55 to 0.98) and those with 3+ comorbidities (RR, 0.68; 95% CL, 0.50 to 0.91) were less likely to receive OAA than those without comorbidities. Patients with higher frailty also had lower OAA utilization (RR, 0.67; 95% CL, 0.52 to 0.85). CONCLUSION These findings suggest a need to better understand the system-level and provider-level drivers of OAA underuse, as well as OAA adherence and associated survival.
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Affiliation(s)
- Stephanie B Wheeler
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill (UNC-CH), Chapel Hill, NC.,Lineberger Comprehensive Cancer Center, UNC-CH, Chapel Hill, NC
| | - Lisa P Spees
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill (UNC-CH), Chapel Hill, NC.,Lineberger Comprehensive Cancer Center, UNC-CH, Chapel Hill, NC
| | | | - Christopher D Baggett
- Lineberger Comprehensive Cancer Center, UNC-CH, Chapel Hill, NC.,Department of Epidemiology, Gillings School of Global Public Health, UNC-CH, Chapel Hill, NC
| | - Lauren E Wilson
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | - Melissa A Greiner
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | - Deborah R Kaye
- Department of Medicine, Duke University School of Medicine, Durham, NC.,Department of Surgery (Urology), Duke University School of Medicine, Durham, NC
| | - Tian Zhang
- Department of Surgery (Urology), Duke University School of Medicine, Durham, NC.,Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC
| | - Daniel George
- Department of Surgery (Urology), Duke University School of Medicine, Durham, NC.,Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC
| | - Charles D Scales
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC.,Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC
| | - Jessica E Pritchard
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | - Michaela A Dinan
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC.,Duke Cancer Institute, Durham, NC
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20
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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] [What about the content of this article? (0)] [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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21
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Ginsburg KB, Jacobs JC, Qi J, Kaye DR, Eggly SS, Linsell SM, Auffenberg GB, George AK, Montie JE, Cher ML. Impact of Early Confirmatory Tests on Upgrading and Conversion to Treatment in Prostate Cancer Patients on Active Surveillance. Urology 2020; 147:213-222. [PMID: 32946908 DOI: 10.1016/j.urology.2020.07.067] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 07/06/2020] [Accepted: 07/27/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To assess the impact of confirmatory tests on active surveillance (AS) biopsy disease reclassification and progression to treatment in men with favorable risk prostate cancer (FRPC). METHODS We searched the MUSIC registry for men with FRPC managed with AS without or with a confirmatory test. Confirmatory tests included (1) repeat prostate biopsy, (2) genomic tests, (3) prostate magnetic resonance imaging (MRI), or (4) MRI followed by a post-MRI biopsy. Confirmatory test results were deemed reassuring (RA) or nonreassuring (nonRA) according to predefined criteria. Kaplan-Meier curves and multivariable Cox regression models were used to compare surveillance biopsy disease reclassification-free survival and treatment-free survival. RESULTS Of the 2,514 men with FRPC who were managed on AS, 1211 (48%) men obtained a confirmatory test. We noted differences in the 12-month unadjusted surveillance biopsy disease reclassification-free probability (68%, 83%, and 90%, P < .0001) and 24-month unadjusted treatment-free probability (55%, 81%, and 79%, P < .0001), for men with nonRA confirmatory tests, no confirmatory test, and RA confirmatory tests, respectively. Excluding patients with genomic confirmatory tests, men with RA confirmatory tests were associated with a lower hazard (hazard ratio [HR] 0.57, 95% confidence interval [CI] 0.38-0.84, P = .005) and men with nonRA confirmatory tests had an increased hazard (HR 1.97, 95% CI 1.22-3.19, P = .006) of surveillance disease reclassification compared with men without confirmatory tests in the multivariable model. CONCLUSION These data suggest men with RA confirmatory tests have less surveillance biopsy reclassification and remain on AS longer than men with nonRA test results. Confirmatory tests may help risk stratify men considering active surveillance.
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Affiliation(s)
| | - Jesse C Jacobs
- Department of Urology, Wayne State University, Detroit, MI
| | - Ji Qi
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - Deborah R Kaye
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI; Department of Urology, University of Michigan, Ann Arbor, MI
| | - Susan S Eggly
- Department of Oncology, Wayne State University/Karmanos Cancer Institute, Detroit, MI
| | - Susan M Linsell
- Department of Urology, University of Michigan, Ann Arbor, MI
| | - Gregory B Auffenberg
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Arvin K George
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI; Department of Urology, University of Michigan, Ann Arbor, MI
| | - James E Montie
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI; Department of Urology, University of Michigan, Ann Arbor, MI
| | - Michael L Cher
- Department of Urology, Wayne State University, Detroit, MI
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22
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Herrel LA, Zhu Z, Griggs JJ, Kaye DR, Dupree JM, Ellimoottil CS, Miller DC. Association Between Delivery System Structure and Intensity of End-of-Life Cancer Care. JCO Oncol Pract 2020; 16:e590-e600. [PMID: 32069191 DOI: 10.1200/jop.19.00667] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To determine whether the type of delivery system is associated with intensity of care at the end of life for Medicare beneficiaries with cancer. PATIENTS AND METHODS We used SEER registry data linked with Medicare claims to evaluate intensity of end-of-life care for patients who died of one of ten common cancers diagnosed from 2009 through 2014. Patients were categorized as receiving the majority of their care in an integrated delivery system, designated cancer center, health system that was both integrated and a certified cancer center, or health system that was neither. We evaluated adherence to seven nationally endorsed end-of-life quality measures using generalized linear models across four delivery system types. RESULTS Among 100,549 beneficiaries who died of cancer during the study interval, we identified only modest differences in intensity of end-of-life care across delivery system structures. Health systems with no cancer center or integrated affiliation demonstrated higher proportions of patients with multiple hospitalizations in the last 30 days of life (11.3%), death in an acute care setting (25.9%), and lack of hospice use in the last year of life (31.6%; all P < .001). Patients enrolled in hospice had lower intensity care across multiple end-of-life quality measures. CONCLUSION Intensity of care at the end of life for patients with cancer was higher at delivery systems with no integration or cancer focus. Maximal supportive care delivered through hospice may be one avenue to reduce high-intensity care at the end of life and may impact quality of care for patients dying from cancer.
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Affiliation(s)
- Lindsey A Herrel
- The University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, MI
| | - Ziwei Zhu
- The University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, MI
| | - Jennifer J Griggs
- The University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, MI
| | - Deborah R Kaye
- The University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, MI
| | - James M Dupree
- The University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, MI
| | - Chandy S Ellimoottil
- The University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, MI
| | - David C Miller
- The University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, MI
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Kaye DR, Luckenbaugh AN, Oerline M, Hollenbeck BK, Herrel LA, Dimick JB, Hollingsworth JM. Understanding the Costs Associated With Surgical Care Delivery in the Medicare Population. Ann Surg 2020; 271:23-28. [PMID: 30601252 PMCID: PMC6586534 DOI: 10.1097/sla.0000000000003165] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Surgical care has been largely untargeted by Medicare payment reforms because episode costs associated with its delivery are not currently well understood. OBJECTIVE To quantify the costs of inpatient and outpatient surgery in the Medicare population. METHODS We analyzed claims data from a 20% national sample of Medicare beneficiaries (2008-2014). For a given study year, we identified all inpatient and outpatient procedures and constructed claims windows around them to define surgical episodes. After summing payments for services rendered during each episode, we totaled all inpatient and outpatient episode payments by surgical specialty. For inpatient episodes, we determined component payments related to the index hospitalization, readmissions, physician services, and postacute care. For outpatient episodes, we differentiated by the site of care (hospital outpatient department versus physician office versus ambulatory surgery center). We used linear regression to evaluate temporal trends in inpatient and outpatient surgical spending. Finally, we estimated the contribution of surgical care to overall Medicare expenditures. RESULTS Total Medicare payments for surgical care are substantial, representing 51% of Program spending in 2014. They declined modestly over the study period, from $133.1 billion in 2008 to $124.9 billion in 2014 (-6.2%, P = 0.085 for the temporal trend). While spending on inpatient surgery contributed the most to total surgical payments (69.4% in 2014), it declined over the study period, driven by decreases in index hospitalization (-16.7%, P = 0.002) and readmissions payments (-27.0%, P = 0.003). In contrast, spending on outpatient surgery increased by $8.5 billion (28.7%, P < 0.001). This increase was realized across all sites of care (hospital outpatient department: 36.6%, P < 0.001; physician office: 22.1%, P < 0.001; ambulatory surgery center: 36.6%, P < 0.001). Ophthalmology and hand surgery witnessed the greatest growth in surgical spending over the study period. CONCLUSIONS AND RELEVANCE Surgical care accounts for half of all Medicare spending. Our findings not only highlight the magnitude of spending on surgery, but also the areas of greatest growth, which could be targeted by future payment reforms.
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Affiliation(s)
- Deborah R. Kaye
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - Amy N Luckenbaugh
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - Mary Oerline
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - Brent K. Hollenbeck
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - Lindsey A. Herrel
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - Justin B Dimick
- Center for Healthcare Outcomes & Policy, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - John M. Hollingsworth
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
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24
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Kaye DR, Dunn RL, Li J, Herrel LA, Dupree JM, Miller DC, Ellimoottil C. Variation in Physician-Specific Episode Payments for Major Cancer Surgery and Implications for the Merit-Based Incentive Program. J Surg Res 2019; 236:30-36. [PMID: 30694769 DOI: 10.1016/j.jss.2018.09.073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 08/22/2018] [Accepted: 09/24/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Nearly 1.5 million clinicians in the United States will be affected by Centers for Medicare and Medicaid Services' (CMS) new payment program, the Merit-based Incentive Program (MIPS), where clinicians will be penalized or rewarded based on the health care expenditures of their patients. We therefore examined expenditures for major cancer surgery to understand physician-specific variation in episode payments. METHODS We used Surveillance, Epidemiology and End Results-Medicare data to identify patients aged 66-99 y who underwent a prostatectomy, nephrectomy, lung, or colorectal resection for cancer from 2008 to 2012. We calculated 90-d episode payments, attributed each episode to a physician, and evaluated physician-level payment variation. Next, we determined which component (index admission, readmission, physician services, postacute care, hospice) drove differences in payments. Finally, we evaluated payments by geographic region, number of comorbidities, and cancer stage. RESULTS We identified 39,109 patients who underwent surgery by 1 of 7182 providers. There was wide variation in payments for each procedure (prostatectomy: $7046-$40,687; nephrectomy: $8855-$82,489; lung resection: $11,167-$223,467; colorectal resection: $9711-$199,480). The largest component difference in episode payments varied by condition: physician payments for prostatectomy (29%), postacute care for nephrectomy (38%) and colorectal resections (38%), and index hospital admission for lung resections (43%) but were fairly stable across region, comorbidity number, and cancer stage. CONCLUSIONS For patients undergoing major cancer surgery, 90-d episode payments vary widely across surgeons. The components driving such variation differ by condition but remain stable across region, number of comorbidities, and cancer stage. These data suggest that programs to reduce specific component payments may have advantages over those targeting individual physicians for decreasing health care expenditures.
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Affiliation(s)
- Deborah R Kaye
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan.
| | - Rodney L Dunn
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Jonathan Li
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Lindsey A Herrel
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - James M Dupree
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - David C Miller
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Chad Ellimoottil
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan
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25
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Kaye DR, Qi J, Morgan TM, Linsell S, Ginsburg KB, Lane BR, Montie JE, Cher ML, Miller DC. Pathological upgrading at radical prostatectomy for patients with Grade Group 1 prostate cancer: implications of confirmatory testing for patients considering active surveillance. BJU Int 2018; 123:846-853. [PMID: 30248225 DOI: 10.1111/bju.14554] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine the association between National Comprehensive Cancer Network (NCCN) risk, number of positive biopsy cores, age, and early confirmatory test results on pathological upgrading at radical prostatectomy (RP), in order to better understand whether early confirmatory testing and better risk stratification are necessary for all men with Grade Group (GG) 1 cancers who are considering active surveillance (AS). PATIENTS AND METHODS We identified men in Michigan initially diagnosed with GG1 prostate cancer, from January 2012 to November 2017, who had a RP within 1 year of diagnosis. Our endpoints were: (i) ≥GG2 cancer at RP and (ii) adverse pathology (≥GG3 and/or ≥pT3a). We compared upgrading according to NCCN risk, number of positive biopsy cores, and age. Last, we examined if confirmatory test results were associated with upgrading or adverse pathology at RP. RESULTS Amongst 1966 patients with GG1 cancer at diagnosis, the rates of upgrading to ≥GG2 and adverse pathology were 40% and 59% (P < 0.001), and 10% and 17% (P = 0.003) for patients with very-low- and low-risk cancers, respectively. Upgrading by volume ranged from 49% to 67% for ≥GG2, and 16% to 23% for adverse pathology. Generally, more patients aged ≥70 vs <70 years had adverse pathology. Unreassuring confirmatory test results had a higher likelihood of adverse pathology than reassuring tests (35% vs 18%, P = 0.017). CONCLUSIONS Upgrading and adverse pathology are common amongst patients initially diagnosed with GG1 prostate cancer. Early use of confirmatory testing may facilitate the identification of patients with more aggressive disease ensuring improved risk classification and safer selection of patients for AS.
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Affiliation(s)
- Deborah R Kaye
- Dow Division of Health Services Research, University of Michigan, Ann Arbor, MI, USA.,University of Michigan, Ann Arbor, MI, USA
| | - Ji Qi
- Dow Division of Health Services Research, University of Michigan, Ann Arbor, MI, USA
| | | | - Susan Linsell
- Dow Division of Health Services Research, University of Michigan, Ann Arbor, MI, USA
| | | | | | - James E Montie
- Dow Division of Health Services Research, University of Michigan, Ann Arbor, MI, USA.,University of Michigan, Ann Arbor, MI, USA
| | - Michael L Cher
- Department of Urology, Wayne State University, Detroit, MI, USA
| | - David C Miller
- Dow Division of Health Services Research, University of Michigan, Ann Arbor, MI, USA.,University of Michigan, Ann Arbor, MI, USA
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26
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Kaye DR, Ye Z, Li J, Herrel LA, Dupree JM, Ellimoottil C, Miller DC. The Stability of Physician-Specific Episode Costs for Urologic Cancer Surgery: Implications for Urologists Under the Merit-Based Incentive Program. Urology 2018; 123:114-119. [PMID: 30125647 DOI: 10.1016/j.urology.2018.04.051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Revised: 04/05/2018] [Accepted: 04/27/2018] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To evaluate the stability of physician-specific episode payments for prostatectomy, nephrectomy, and cystectomy in the context of value-based purchasing programs, such as the merit-based incentive payment system. METHODS We utilized Surveillance, Epidemiology and End Results-Medicare data to identify patients aged 66-99 who underwent a prostatectomy, nephrectomy, or cystectomy from 2008 to 2012. We calculated each surgeon's average 90-day episode payment by procedure. Next, we examined payment differences between the most and least expensive quartile providers. For the most expensive quartile of physicians in 2010, we examined their spending quartile in 2011. Finally, we evaluated the correlation in spending over time and across procedures. RESULTS We identified 14,585 patients who underwent surgery by one of 1895 unique clinicians. Differences in payments between the highest and lowest quartiles were $5881, $17,714, and $40,288 for prostatectomy, nephrectomy, and cystectomy, respectively. Only 39%, 16%, and 13% of physicians that were in the highest spending quartile for prostatectomy, nephrectomy, and cystectomy in 2010 were also in the most expensive quartile in 2011. Although we observed weak correlation in year-to-year spending for prostatectomy (0.108, P = .033 to .270, P < .001), annual payments for nephrectomy and cystectomy were not significantly correlated. Finally, there was minimal correlation in surgeon spending across procedures. CONCLUSION There is wide variation in physician-specific episode payments for prostatectomy, nephrectomy, and cystectomy. However, physician spending patterns are not stable over time or across procedures, raising concerns about the ability of the cost-based measures in merit-based incentive payment system to change physician behavior and reliably distinguish those providing less efficient or lower quality care.
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Affiliation(s)
- Deborah R Kaye
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI.
| | - Zaojun Ye
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - Jonathan Li
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - Lindsey A Herrel
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - James M Dupree
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - Chad Ellimoottil
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - David C Miller
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
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Abstract
Using SEER‐Medicare data, this article demonstrates that considerable differences exist in expenditures across phases of care and varying patient characteristics. These findings can help to provide a better understanding of the drivers of payment variation across patient and tumor characteristics to inform efforts to decrease costs and increase quality of cancer care. Purpose. The aim of this study was to estimate Medicare payments for cancer care during the initial, continuing, and end‐of‐life phases of care for 10 malignancies and to examine variation in expenditures according to patient characteristics and cancer severity. Materials and Methods. We used linked Surveillance, Epidemiology and End Results‐Medicare data to identify patients aged 66–99 years who were diagnosed with one of the following 10 cancers: prostate, bladder, esophageal, pancreatic, lung, liver, kidney, colorectal, breast, or ovarian, from 2007 through 2012. We attributed payments for each patient to a phase of care (i.e., initial, continuing, or end of life), based on time from diagnosis until death or end of study interval. We summed payments for all claims attributable to the primary cancer diagnosis and analyzed the overall and phase‐based costs and then by differing demographics, cancer stage, geographic region, and year of diagnosis. Results. We identified 428,300 patients diagnosed with one of the 10 malignancies. Annual payments were generally highest during the initial phase. Mean expenditures across cancers were $14,381 during the initial phase, $2,471 for continuing, and $13,458 at end of life. Payments decreased with increasing age. Black patients had higher payments for four of five cancers with statistically significant differences. Stage III cancers posed the greatest annual cost burden for four cancer types. Overall payments were stable across geographic region and year. Conclusion. Considerable differences exist in expenditures across phases of cancer care. By understanding the drivers of such payment variations across patient and tumor characteristics, we can inform efforts to decrease payments and increase quality, thereby reducing the burden of cancer care. Implications for Practice. Considerable differences exist in expenditures across phases of cancer care. There are further differences by varying patient characteristics. Understanding the drivers of such payment variations across patient and tumor characteristics can inform efforts to decrease costs and increase quality, thereby reducing the burden of cancer care.
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Affiliation(s)
- Deborah R Kaye
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - Hye Sung Min
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - Lindsey A Herrel
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - James M Dupree
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - Chad Ellimoottil
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - David C Miller
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
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Kaye DR, Min HS, Norton EC, Ye Z, Li J, Dupree JM, Ellimoottil C, Miller DC, Herrel LA. System-Level Health-Care Integration and the Costs of Cancer Care Across the Disease Continuum. J Oncol Pract 2018; 14:e149-e157. [PMID: 29443647 DOI: 10.1200/jop.2017.027730] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
PURPOSE Policy reforms in the Affordable Care Act encourage health care integration to improve quality and lower costs. We examined the association between system-level integration and longitudinal costs of cancer care. METHODS We used linked SEER-Medicare data to identify patients age 66 to 99 years diagnosed with prostate, bladder, esophageal, pancreatic, lung, liver, kidney, colorectal, breast, or ovarian cancer from 2007 to 2012. We attributed each patient to one or more phases of care (ie, initial, continuing, and end of life) according to time from diagnosis until death or end of study interval. For each phase, we aggregated all claims with the primary cancer diagnosis and identified patients treated in an integrated delivery network (IDN), as defined by the Becker Hospital Review list of the top 100 most integrated health delivery systems. We then determined if care provided in an IDN was associated with decreased payments across cancers and for each individual cancer by phase and across phases. RESULTS We identified 428,300 patients diagnosed with one of 10 common cancers. Overall, there were no differences in phase-based payments between IDNs and non-IDNs. Average adjusted annual payments by phase for IDN versus non-IDNs were as follows: initial, $14,194 versus $14,421, respectively ( P = .672); continuing, $2,051 versus $2,099 ( P = .566); and end of life, $16,257 versus $16,232 ( P = .948). However, in select cancers, we observed lower payments in IDNs. For bladder cancer, payments at the end of life were lower for IDNs ($11,041 v $12,331; P = .008). Of the four cancers with the lowest 5-year survival rates (ie, pancreatic, lung, esophageal, and liver), average expenditures during the initial and continuing-care phases were lower for patients with liver cancer treated in IDNs. CONCLUSION For patients with one of 10 common malignancies, treatment in an IDN generally is not associated with lower costs during any phase of cancer care.
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Affiliation(s)
| | - Hye Sung Min
- All authors: University of Michigan, Ann Arbor, MI
| | | | - Zaojun Ye
- All authors: University of Michigan, Ann Arbor, MI
| | - Jonathan Li
- All authors: University of Michigan, Ann Arbor, MI
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29
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Kaye DR, Syrjamaki J, Ellimoottil C, Schervish EW, Solomon MH, Linsell S, Montie JE, Miller DC, Dupree JM. Use of Routine Home Health Care and Deviations From an Uncomplicated Recovery Pathway After Radical Prostatectomy. Urology 2017; 112:74-79. [PMID: 29155190 DOI: 10.1016/j.urology.2017.11.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 11/02/2017] [Accepted: 11/03/2017] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To evaluate the statistical association between routine home health use after prostatectomy, short-term surgical outcomes, and payments. METHODS We identified all men who underwent a robotic radical prostatectomy from April 1, 2014, to October 31, 2015, in the Michigan Urological Surgery Improvement Collaborative (MUSIC) with insurance from Medicare or a large commercial payer. We calculated rates of "routine" home care use after prostatectomy by urology practice. We defined "routine" home care as home care initiated within 4 days of discharge among patients discharged without a pelvic drain. We then compared emergency department (ED) visits, readmissions, prolonged catheter use, catheter reinsertion rates, and 90-day episode payments, in unadjusted and using a propensity-adjusted analysis, for those who did and did not receive home care. RESULTS We identified 647 patients, of whom 13% received routine home health care. At the practice level, the use of routine home care after prostatectomy varied from 0% to 53% (P = .05) (mean: 3.6%, median: 0%). Unadjusted, patients with routine home care had increased ED visits within 16 days (15.5% vs 6.9%, P <.01), similar rates of catheter duration for >16 days (3.6% vs 3.0%, P = .79) and need for catheter replacement (1.2% vs 2.5%, P = .46), and a trend toward decreased readmissions (0% vs 4.1%, P = .06). Only the increased ED visits remained significant in adjusted analyses (P <.01). Home health had an average payment of $1000 per episode. CONCLUSION Thirteen percent of patients received routine home health care after prostatectomy, without improved outcomes. These findings suggest that patients do not routinely require home health care to improve short-term outcomes following radical prostatectomy, however, the appropriate use of home health care should be evaluated further.
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Affiliation(s)
- Deborah R Kaye
- Michigan Urological Surgery Improvement Collaborative, Ann Arbor, MI; Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI; Michigan Value Collaborative, Ann Arbor, MI.
| | - John Syrjamaki
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI; Michigan Value Collaborative, Ann Arbor, MI
| | - Chad Ellimoottil
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI; Michigan Value Collaborative, Ann Arbor, MI
| | - Edward W Schervish
- Michigan Urological Surgery Improvement Collaborative, Ann Arbor, MI; Michigan Institute of Urology, Detroit, MI
| | - M Hugh Solomon
- Michigan Urological Surgery Improvement Collaborative, Ann Arbor, MI
| | - Susan Linsell
- Michigan Urological Surgery Improvement Collaborative, Ann Arbor, MI; Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - James E Montie
- Michigan Urological Surgery Improvement Collaborative, Ann Arbor, MI; Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - David C Miller
- Michigan Urological Surgery Improvement Collaborative, Ann Arbor, MI; Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI; Michigan Value Collaborative, Ann Arbor, MI
| | - James M Dupree
- Michigan Urological Surgery Improvement Collaborative, Ann Arbor, MI; Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI; Michigan Value Collaborative, Ann Arbor, MI
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Kaye DR, Richardson CR, Ye Z, Herrel LA, Ellimoottil C, Miller DC. Association Between Patient Satisfaction and Short-Term Outcomes After Major Cancer Surgery. Ann Surg Oncol 2017; 24:3486-3493. [PMID: 28819930 PMCID: PMC5780185 DOI: 10.1245/s10434-017-6049-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The aim of this study was to investigate whether patient satisfaction, as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, is associated with short-term outcomes after major cancer surgery. MATERIALS AND METHODS We first used national Medicare claims to identify patients who underwent a major extirpative cancer surgery from 2011 to 2013. Next, we used Hospital Compare data to assign the HCAHPS score to the hospital where the patient underwent surgery. We then performed univariate statistical analyses and fit multilevel logistic regression models to evaluate the relationship between excellent patient satisfaction and short-term cancer surgery outcomes for all surgery types combined and then by each individual surgery type. RESULTS We identified 373,692 patients who underwent major cancer surgery for one of nine cancers at 2617 hospitals. In both unadjusted and adjusted analyses, hospitals with higher proportions of patients reporting excellent satisfaction had lower complication rates (p < 0.001), readmissions (p < 0.001), mortality (p < 0.001), and prolonged length of stay (p < 0.001) than hospitals with lower proportions of satisfied patients, but with modest differences. This finding held true broadly across individual cancer types for complications, mortality, and prolonged length of stay, but less so for readmissions. CONCLUSIONS Hospital-wide excellent patient satisfaction scores are associated with short-term outcomes after major cancer surgery overall, but are modest in magnitude.
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Affiliation(s)
- Deborah R Kaye
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI, USA.
| | - Caroline R Richardson
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Department of Family Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Zaojun Ye
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - Lindsey A Herrel
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Chad Ellimoottil
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - David C Miller
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
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Kaye DR, Norton EC, Ellimoottil C, Ye Z, Dupree JM, Herrel LA, Miller DC. Understanding the relationship between the Centers for Medicare and Medicaid Services' Hospital Compare star rating, surgical case volume, and short-term outcomes after major cancer surgery. Cancer 2017; 123:4259-4267. [PMID: 28665483 DOI: 10.1002/cncr.30866] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 05/23/2017] [Accepted: 06/06/2017] [Indexed: 11/08/2022]
Abstract
BACKGROUND Both the Centers for Medicare and Medicaid Services' (CMS) Hospital Compare star rating and surgical case volume have been publicized as metrics that can help patients to identify high-quality hospitals for complex care such as cancer surgery. The current study evaluates the relationship between the CMS' star rating, surgical volume, and short-term outcomes after major cancer surgery. METHODS National Medicare data were used to evaluate the relationship between hospital star ratings and cancer surgery volume quintiles. Then, multilevel logistic regression models were fit to examine the association between cancer surgery outcomes and both star rankings and surgical volumes. Lastly, a graphical approach was used to compare how well star ratings and surgical volume predicted cancer surgery outcomes. RESULTS This study identified 365,752 patients undergoing major cancer surgery for 1 of 9 cancer types at 2,550 hospitals. Star rating was not associated with surgical volume (P < .001). However, both the star rating and surgical volume were correlated with 4 short-term cancer surgery outcomes (mortality, complication rate, readmissions, and prolonged length of stay). The adjusted predicted probabilities for 5- and 1-star hospitals were 2.3% and 4.5% for mortality, 39% and 48% for complications, 10% and 15% for readmissions, and 8% and 16% for a prolonged length of stay, respectively. The adjusted predicted probabilities for hospitals with the highest and lowest quintile cancer surgery volumes were 2.7% and 5.8% for mortality, 41% and 55% for complications, 12.2% and 11.6% for readmissions, and 9.4% and 13% for a prolonged length of stay, respectively. Furthermore, surgical volume and the star rating were similarly associated with mortality and complications, whereas the star rating was more highly associated with readmissions and prolonged length of stay. CONCLUSIONS In the absence of other information, these findings suggest that the star rating may be useful to patients when they are selecting a hospital for major cancer surgery. However, more research is needed before these ratings can supplant surgical volume as a measure of surgical quality. Cancer 2017;123:4259-4267. © 2017 American Cancer Society.
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Affiliation(s)
- Deborah R Kaye
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Edward C Norton
- Department of Health Management and Policy, University of Michigan, Ann Arbor, Michigan.,Department of Economics, University of Michigan, Ann Arbor, Michigan.,National Bureau of Economic Research, Cambridge, Massachusetts
| | - Chad Ellimoottil
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Zaojun Ye
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - James M Dupree
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Lindsey A Herrel
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - David C Miller
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan
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Kaye DR, Ellimootil C, Dupree JM, Ye Z, Herrel LA, Sung Min H, Norton EC, Miller DC. PD14-02 CENTERS FOR MEDICARE AND MEDICAID SERVICES' (CMS) HOSPITAL COMPARE STAR RANKINGS AND SHORT-TERM OUTCOMES AFTER MAJOR UROLOGICAL CANCER SURGERY. J Urol 2017. [DOI: 10.1016/j.juro.2017.02.703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Kaye DR, Canner JK, Kates M, Schoenberg MP, Bivalacqua TJ. Do African American Patients Treated with Radical Cystectomy for Bladder Cancer have Worse Overall Survival? Accounting for Pathologic Staging and Patient Demographics Beyond Race Makes a Difference. Bladder Cancer 2016; 2:225-234. [PMID: 27376141 PMCID: PMC4927827 DOI: 10.3233/blc-150041] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: It is estimated that 74,000 men and women in the United States will be diagnosed with bladder cancer and 16,000 will die from the disease in 2015. The incidence of bladder cancer in Caucasian males is double that of African American males, but African American men and women have worse survival. Although factors contributing to this disparity have been analyzed, there is still great uncertainty as to why this disparity exists. Objective: To evaluate whether the disparities in bladder cancer survival after radical cystectomy for transitional cell carcinoma (TCC) of the bladder amongst African American (AA) and Caucasian patients is attributable to patient demographics, year of diagnosis, and/or tumor characteristics. Methods: Using Surveillance, Epidemiology, and End Results Program (SEER) data from 1973–2011, African American and Caucasian patients treated with a radical cystectomy for TCC of the bladder were identified. Primary outcomes were all-cause and cancer-specific mortality. Differences in survival between African Americans and Caucasian patients were assessed using chi-square tests for categorical variables and Student’s t-tests for continuous variables. Cox proportional hazards regression was used to measure the hazard ratio for African Americans compared to Caucasians for all-cause and cancer-specific mortality. In addition, coarsened matching techniques within narrow ranges, were used to match African American and Caucasian patients on the basis of age, sex, and cancer stage. Following matching, differences in all-cause and cancer-specific mortality were again assessed using a stratified Cox proportional hazards model, using the matching strata for the regression strata. Results: The study cohort consisted of 21,406 African American and Caucasian patients treated with radical cystectomy for bladder urothelial cancer, with 6.2% being African American and 73.9% male. African American patients had worse all-cause and cancer-specific mortality in the univariable analysis (all-cause: HR: 1.23; 95% CI 1.15–1.32, p < 0.001); bladder-cancer specific: HR 1.21; 95% CI 1.11–1.33; p < 0.001). However, after accounting for sex, age, year of diagnosis, marital status, region of treatment, and stage at cystectomy, all-cause mortality was significant (HR 1.20; 95% CI 1.12–1.29; p < 0.0001), but not bladder-cancer specific mortality (HR 1.09; 95% CI 1.00–1.20; p < 0.053). Predictors of bladder cancer specific mortality were age, sex, stage of disease, and marital status. The matched analysis yielded a roughly 1 : 15 match, with 22,511 Caucasians being matched to 1,509 African American patients. In the matched analysis, African Americans had increased all-cause mortality (HR 1.17; 95% CI 1.09–1.26; p < 0.0001), but bladder-cancer specific mortality was no longer significant (HR 1.08; 95% CI 0.99–1.18; p < 0.102). Conclusions: African Americans who undergo a cystectomy are more likely to die, but not necessarily solely because of bladder cancer. Although African American patients have worse all-cause and cancer-specific mortality in univariable models, after controlling for sex, age, year of diagnosis, marital status, region of treatment, and stage at cystectomy, African American patients still have worse overall survival, but equivalent bladder-cancer specific survival. Differences in age, sex, and stage at diagnosis explain some, but not all of the differences in survival.
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Affiliation(s)
- Deborah R Kaye
- Department of Urology, The James Buchanan Brady Urological Institute , The Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Joseph K Canner
- Center for Surgical Trials and Outcomes Research , Department of General Surgery, The Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Max Kates
- Department of Urology, The James Buchanan Brady Urological Institute , The Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Mark P Schoenberg
- Department of Urology, Montefiore Medical Center and Albert Einstein College of Medicine , Bronx, NY, USA
| | - Trinity J Bivalacqua
- Department of Urology, The James Buchanan Brady Urological Institute , The Johns Hopkins School of Medicine, Baltimore, MD, USA
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Chappidi MR, Kates M, Patel HD, Tosoian JJ, Kaye DR, Sopko NA, Lascano D, Liu JJ, McKiernan J, Bivalacqua TJ. Frailty as a marker of adverse outcomes in patients with bladder cancer undergoing radical cystectomy. Urol Oncol 2016; 34:256.e1-6. [PMID: 26899289 DOI: 10.1016/j.urolonc.2015.12.010] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Revised: 12/15/2015] [Accepted: 12/20/2015] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To investigate the modified frailty index (mFI) as a preoperative predictor of postoperative complications following radical cystectomy (RC) in patients with bladder cancer. MATERIALS AND METHODS Patients undergoing RC were identified from the National Surgical Quality Improvement Program participant use files (2011-2013). The mFI was defined in prior studies with 11 variables based on mapping the Canadian Study of Health and Aging Frailty Index to the National Surgical Quality Improvement Program comorbidities and activities of daily livings. The mFI groups were determined by the number of risk factors per patient (0, 1, 2, and≥3). Univariable and multivariable regression were performed to determine predictors of Clavien 4 and 5 complications, and a sensitivity analysis was performed to determine the mFI value that would be a significant predictor of Clavien 4 and 5 complications. RESULTS Of the 2,679 cystectomy patients identified, 843 (31%) of patients had an mFI of 0, 1176 (44%) had an mFI of 1, 555 (21%) had an mFI of 2, and 105 (4%) had an mFI≥3. Overall, 1585 (59%) of patients experienced a Clavien complication. When stratified at a cutoff of mFI≥2, the overall complication rate was not different (61.7% vs. 58.3%, P = 0.1), but the mFI2 or greater group had a significantly higher rate of Clavien grade 4 or 5 complications (14.6% vs. 8.3%, P<0.001) and overall mortality rate (3.5% vs. 1.8%, P = 0.01) in the 30-day postoperative period. The multivariate logistic regression model showed independent predictors of Clavien grade 4 or 5 complications were age>80 years (odds ratio [OR] = 1.58 [1.11-2.27]), mFI2 (OR = 1.84 [1.28-2.64]), and mFI3 (OR = 2.58 [1.47-4.55]). CONCLUSIONS Among patients undergoing RC, the mFI can identify those patients at greatest risk for severe complications and mortality. Given that bladder cancer is increasing in prevalence particularly among the elderly, preoperative risk stratification is crucial to inform decision-making about surgical candidacy.
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Affiliation(s)
- Meera R Chappidi
- The James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, MD.
| | - Max Kates
- The James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Hiten D Patel
- The James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Jeffrey J Tosoian
- The James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Deborah R Kaye
- The James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Nikolai A Sopko
- The James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Danny Lascano
- Department of Urology, Herbert Irving Cancer Center, Columbia University College of Physicians and Surgeons, New York, NY
| | - Jen-Jane Liu
- The James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, MD
| | - James McKiernan
- Department of Urology, Herbert Irving Cancer Center, Columbia University College of Physicians and Surgeons, New York, NY
| | - Trinity J Bivalacqua
- The James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, MD
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Kaye DR, Pinto PA, Cecchi F, Reilly J, Semerjian A, Giubellino A, Gupta G, Choyke PL, Linehan WM, Bottaro DP. MP6-17 PREDICTIVE VALUE OF PLASMA SOLUBLE MET PROTEIN CONCENTRATION IN PATIENTS WITH PROSTATE CANCER. J Urol 2015. [DOI: 10.1016/j.juro.2015.02.264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Kaye DR, Hyndman ME, Segal RL, Mettee LZ, Trock BJ, Feng Z, Su LM, Bivalacqua TJ, Pavlovich CP. Urinary Outcomes Are Significantly Affected by Nerve Sparing Quality During Radical Prostatectomy. Urology 2013; 82:1348-53. [DOI: 10.1016/j.urology.2013.06.067] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2013] [Revised: 06/01/2013] [Accepted: 06/12/2013] [Indexed: 11/29/2022]
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Affiliation(s)
- Robert A Berenson
- From the Urban Institute, Washington, DC (R.A.B.); and the Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore (D.R.K.)
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Kaye DR, Walsh PC, Netto GJ, Gonzalez-Roibon N, Rodriguez R. A 66-year-old man with prostate-specific antigen recurrence and lung mass after radical prostatectomy. Urology 2012; 80:247-9. [PMID: 22673543 DOI: 10.1016/j.urology.2012.03.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2011] [Revised: 02/13/2012] [Accepted: 03/09/2012] [Indexed: 11/29/2022]
Affiliation(s)
- Deborah R Kaye
- Department of Urology, The James Buchanan Brady Urological Institute, Johns Hopkins Hospital, Baltimore, MD 21287-2101, USA.
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Kaye DR, Storey BB, Pacak K, Pinto PA, Linehan WM, Bratslavsky G. Partial adrenalectomy: underused first line therapy for small adrenal tumors. J Urol 2010; 184:18-25. [PMID: 20546805 DOI: 10.1016/j.juro.2010.03.052] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2009] [Indexed: 12/14/2022]
Abstract
PURPOSE Many patients with small adrenal masses undergo total adrenalectomy. We evaluated partial adrenalectomy outcomes by performing a comprehensive literature review. MATERIALS AND METHODS We performed a PubMed search of the English language literature using the queries partial adrenalectomy and adrenal sparing surgery, and identified 317 and 155 articles, respectively. We excluded case reports or series with fewer than 5 patients, articles not focused on surgical management and those that did not indicate perioperative outcomes. The remaining articles were cross-referenced by author and institution to eliminate studies with redundant cases. Demographics, diagnosis, tumor characteristics, perioperative and functional outcomes, and recurrence data were collected when available. RESULTS A total of 22 articles from a total of 22 first authors met our inclusion criteria, describing outcomes in a total of 417 patients. There has been an increasing trend toward partial adrenalectomy worldwide in the last 20 years. Partial adrenalectomy is most commonly done for Conn's syndrome, followed by pheochromocytoma. Most procedures are laparoscopic with minimal morbidity. The recurrence rate is only 3% and more than 90% of patients remain steroid independent. CONCLUSIONS Partial adrenalectomy surgical outcomes and perioperative complications are similar to those reported for total adrenalectomy. When partial adrenalectomy is done for small adrenal lesions, the malignancy rate is negligible, the recurrence rate is low and most patients remain steroid-free at long-term followup. These data strongly support the acceptance of partial adrenalectomy as first line treatment for small adrenal masses.
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Affiliation(s)
- Deborah R Kaye
- Urologic Oncology Branch, National Cancer Institute and Section on Neuroendocrinology, National Institute of Child Health and Human Development (BBS, KP), National Institutes of Health, Bethesda, Maryland, USA
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Storey BB, Gupta G, Proano J, Lankford D, Kaye DR, Locklin J, Krill A, Kruecker J, Xu S, Bratslavsky G, Glossop N, Glenn L, Wood B, Menalo J, Pinto PA. A NOVEL PLATFORM FOR IMAGE FUSED ELECTROMAGNETIC TRACKED PERCUTANEOUS RFA OF RENAL CELL CARCINOMA. J Urol 2009. [DOI: 10.1016/s0022-5347(09)60524-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Kaye DR, Proano JM, Boris RS, Pinto PA, Linehan WM, Gennady B. ROBOTIC ASSISTED PARTIAL NEPHRECTOMY FOR HEREDITARY RENAL CANCERS: THE NCI EXPERIENCE. J Urol 2009. [DOI: 10.1016/s0022-5347(09)61327-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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