Implementation of medical scribes in an academic urology practice: an analysis of productivity, revenue, and satisfaction

PURPOSE

Pressure on physicians to increase productivity is rising in parallel with administrative tasks, regulations, and the use of electronic health records (EHRs). Physician extenders and clinical pathways are already in use to increase productivity and reduce costs and burnout, but other strategies are required. We evaluated whether implementation of medical scribes in an academic urology clinic would affect productivity, revenue, and patient/provider satisfaction.

METHODS

Six academic urologists were assigned scribes for 1 clinic day per week for 3 months. Likert-type patient and provider surveys were developed to evaluate satisfaction with and without scribes. Matched clinic days in the year prior were used to evaluate changes in productivity and physician/hospital charges and revenue.

RESULTS

After using scribes for 3 months, providers reported increased efficiency (p value = 0.03) and work satisfaction (p value = 0.03), while seeing a mean 2.15 more patients per session (+ 0.96 return visits, + 0.99 new patients, and + 0.22 procedures), contributing to an additional 2.6 wRVUs, $542 in physician charges, and $861 in hospital charges per clinic session. At a gross collection rate of 36%, actual combined revenue was + $506/session, representing a 26% increase in overall revenue. At a cost of $77/session, the net financial impact was + $429 per clinic session, resulting in a return-to-investment ratio greater than 6:1, while having no effect on patient satisfaction scores. Additionally, with scribes, clinic encounters were closed a mean 8.9 days earlier.

CONCLUSIONS

Implementing medical scribes in academic urology practices may be useful in increasing productivity, revenue, and provider satisfaction, while maintaining high patient satisfaction.

Medical and Surgical Treatment Modalities for Lower Urinary Tract Symptoms in the Male Patient Secondary to Benign Prostatic Hyperplasia: A Review

Benign prostatic hyperplasia (BPH) with lower urinary tract symptoms (LUTS) is one of the most common ailments affecting aging men. Symptoms typically associated with BPH include weak stream, hesitancy, urgency, frequency, and nocturia. More serious complications of BPH include urinary retention, gross hematuria, bladder calculi, recurrent urinary tract infection, obstructive uropathy, and renal failure. Evaluation of BPH includes a detailed history, objective assessment of urinary symptoms with validated questionnaires, and measurement of bladder function parameters, including uroflowmetry and postvoid residual. In general, treatment of LUTS associated with BPH is based on the effect of the symptoms on quality of life (QOL) and include medical therapy aimed at reducing outlet obstruction or decreasing the size of the prostate. If medical therapy fails or is contraindicated, various surgical options exist. As the elderly population continues to grow, the management of BPH will become more common and important in maintaining patient's QOL.

Gender Differences in Compensation, Job Satisfaction and Other Practice Patterns in Urology

PURPOSE

The proportion of women in urology has increased from less than 0.5% in 1981 to 10% today. Furthermore, 33% of students matching in urology are now female. In this analysis we characterize the female workforce in urology compared to that of men with regard to income, workload and job satisfaction.

MATERIALS AND METHODS

We collaborated with the American Urological Association to survey its domestic membership of practicing urologists regarding socioeconomic, workforce and quality of life issues. A total of 6,511 survey invitations were sent via e-mail. The survey consisted of 26 questions and took approximately 13 minutes to complete. Linear regression models were used to evaluate bivariable and multivariable associations with job satisfaction and compensation.

RESULTS

A total of 848 responses (660 or 90% male, 73 or 10% female) were collected for a total response rate of 13%. On bivariable analysis female urologists were younger (p <0.0001), more likely to be fellowship trained (p=0.002), worked in academics (p=0.008), were less likely to be self-employed and worked fewer hours (p=0.03) compared to male urologists. On multivariable analysis female gender was a significant predictor of lower compensation (p=0.001) when controlling for work hours, call frequency, age, practice setting and type, fellowship training and advance practice provider employment. Adjusted salaries among female urologists were $76,321 less than those of men. Gender was not a predictor of job satisfaction.

CONCLUSIONS

Female urologists are significantly less compensated compared to male urologists after adjusting for several factors likely contributing to compensation. There is no difference in job satisfaction between male and female urologists.

Robotic ureteral reconstruction distal to the ureteropelvic junction: a large single institution clinical series with short-term follow up

BACKGROUND AND PURPOSE

Use of the robotic platform for urinary reconstructive surgery is growing in popularity since its initial application with pyeloplasty for ureteropelvic junction (UPJ) repair. Although clinical series of adult robotic ureteral reconstruction appear in the literature, these reports tend to be limited in size and scope. We present the largest series to date of patients undergoing surgery for any obstruction distal to the UPJ along with outcomes and short-term follow up.

PATIENTS AND METHODS

A retrospective chart review was performed for patients undergoing robotic ureteral reconstructive procedures for any indication at our institution. Patients undergoing pyeloplasty, planned open procedures, and pediatric patients were excluded from the current analysis. Patient demographic data, etiology, procedure performed, and perioperative outcomes were reviewed. Postoperative follow up, imaging, and any re-interventions were also captured. The procedures performed included ureteroneocystostomy, psoas hitch, Boari flap, ureteroureterostomy, ureterolysis, ureterolithotomy, and nephropexy.

RESULTS

A total of 55 patients underwent robotic ureteral reconstructive procedures distal to the UPJ. Of these patients, 45 underwent intervention for a benign etiology and 10 for upper tract malignancy. All cases were successfully completed robotically with no open conversions and no intraoperative complications. Concurrent endoscopy was performed in 31 patients. The median operating room time was 221 minutes overall. Median blood loss was 50 ml with no intraoperative transfusions. The average hospital stay was 1.6 days, with 39 patients (71%) discharged on postoperative day 1. All surgical margins were negative for malignancy. The median follow up with imaging was 181 days. There were two serious complications (3.6%) and three failures (5.3%).

CONCLUSIONS

Robotic reconstruction of the ureter distal to the UPJ is feasible, safe, effective, and able to replicate techniques of open surgery with equivalent outcomes to large robotic pyeloplasty and smaller distal ureteral reconstruction series.

Resident involvement and experience do not affect perioperative complications following robotic prostatectomy

PURPOSE

Most urologic training programs use robotic prostatectomy (RP) as an introduction to teach residents appropriate robotic technique. However, concerns may exist regarding differences in RP outcomes with resident involvement. Our objective was therefore to evaluate whether resident involvement affects complications, operative time, or length of stay (LOS) following RP.

METHODS

Using the National Surgical Quality Improvement Program database (2005-2011), we identified patients who underwent RP, stratified them by resident presence or absence during surgery, and compared hospital LOS, operative time, and postoperative complications using bivariable and multivariable analyses. A secondary analysis comparing outcomes of interest across postgraduate year (PGY) levels was also performed.

RESULTS

A total of 5,087 patients who underwent RPs were identified, in which residents participated in 56%, during the study period. After controlling for potential confounders, resident present and absent groups were similar in 30-day mortality (0.0 vs. 0.2%, p = 0.08), serious morbidity (1.8 vs. 2.1%, p = 0.33), and overall morbidity (5.1 vs. 5.4%, p = 0.70). While resident involvement did not affect LOS, operative time was longer when residents were present (median 208 vs. 183 min, p < 0.001). Similar findings were noted when assessing individual PGY levels.

CONCLUSIONS

Regardless of PGY level, resident involvement in RPs appears safe and does not appear to affect postoperative complications or LOS. While resident involvement in RPs does result in longer operative times, this is necessary for the learning process.

Readability of American online patient education materials in urologic oncology: a need for simple communication

OBJECTIVE

To determine the readability levels of reputable cancer and urologic Web sites addressing bladder, prostate, kidney, and testicular cancers.

METHODS

Online patient education materials (PEMs) for bladder, prostate, kidney, and testicular malignancies were evaluated from the American Cancer Society, American Society of Clinical Oncology, National Cancer Institute, Urology Care Foundation, Bladder Cancer Advocacy Network, Prostate Cancer Foundation, Kidney Cancer Association, and Testicular Cancer Resource Center. Grade level was determined using several readability indices, and analyses were performed on the basis of cancer type, Web site, and content area (general, causes, risk factors and prevention, diagnosis and staging, treatment, and post-treatment).

RESULTS

Estimated grade level of online PEMs ranged from 9.2 to 14.2 with an overall mean of 11.7. Web sites for kidney cancer had the least difficult readability (11.3) and prostate cancer had the most difficult readability (12.1). Among specific Web sites, the most difficult readability levels were noted for the Urology Care Foundation Web site for bladder and prostate cancer and the Kidney Cancer Association and Testicular Cancer Resource Center for kidney and testes cancer. Readability levels within content areas varied on the basis of the disease and Web site.

CONCLUSION

Online PEMs in urologic oncology are written at a level above the average American reader. Simplification of these resources is necessary to improve patient understanding of urologic malignancy.

Preoperatively misclassified, surgically removed benign renal masses: a systematic review of surgical series and United States population level burden estimate

PURPOSE

A significant proportion of renal masses removed for suspected malignancy are histologically benign with the probability inversely proportional to lesion size. To our knowledge the number of preoperatively misclassified benign renal masses treated with nephrectomy is currently unknown. Given the increasing incidence and decreasing average size of renal cell carcinoma, this burden is likely increasing. We estimated the population level burden of surgically removed, preoperatively misclassified benign renal masses in the United States.

MATERIALS AND METHODS

We systematically reviewed the literature for studies of pathological findings of renal masses removed for suspected renal cell carcinoma based on preoperative imaging through July 1, 2014. We excluded studies that did not describe benign pathology and with masses not stratified by size, and in which pathology results were based on biopsy. SEER data were queried for the incidence of surgically removed renal cell carcinomas in 2000 to 2009.

RESULTS

A total of 19 studies of tumor pathology based on size met criteria for review. Pooled estimates of the proportion of benign histology in our primary analysis (American studies only and 1 cm increments) were 40.4%, 20.9%, 19.6%, 17.2%, 9.2% and 6.4% for tumors less than 1, 1 to less than 2, 2 to less than 3, 3 to less than 4, 4 to 7 and greater than 7, respectively. The estimated number of surgically resected benign renal masses in the United States from 2000 to 2009 increased by 82% from 3,098 to 5,624.

CONCLUSIONS

These estimates suggest that the population level burden of preoperatively misclassified benign renal masses is substantial and increasing rapidly, paralleling increases in surgically resected small renal cell carcinoma. This study illustrates an important and to our knowledge previously unstudied dimension of overtreatment that is not directly quantified in contemporary surveillance data.

Prevention and management of complications following robot-assisted radical cystectomy: lessons learned after >250 consecutive cases

INTRODUCTION

Numerous case series of robot-assisted radical cystectomy have emerged which describe complication rates comparable to open series. However, various reports have outlined preoperative factors as predictors of postoperative complications. Understanding these factors and the methods to optimize the perioperative care of the robotic cystectomy patient is essential for successful outcomes.

METHODS

In this topic paper, we briefly review the literature surrounding complication rates following robot-assisted radical cystectomy as well as describe our experience after >250 cases, outlining our suggestions for avoidance of surgical complications when building a practice that incorporates this technique.

RESULTS

Due to numerous variables, there are a number of intra-operative considerations, including patient selection, perioperative care pathway, intra-operative technique, and equipment choice that we have found to decrease post-operative complications and improve patient outcomes.

CONCLUSION

Through careful patient selection, use of appropriate equipment and perioperative surgical management, robotic cystectomy is a feasible procedure with excellent perioperative results.

Dorsal penile nerve block prior to inflatable penile prosthesis placement: a randomized, placebo-controlled trial

INTRODUCTION

Dorsal penile nerve block (DPNB) has been previously shown to provide effective analgesia for penile surgeries. To date, few studies have examined the role of DPNB prior to inflatable penile prosthesis (IPP) implantation.

AIM

The purpose of this study was to assess the efficacy of local penile nerve block prior to IPP implantation for postoperative pain control.

MAIN OUTCOME MEASURES

The primary outcome was postoperative pain rated using the visual analog scale (VAS). Secondary outcome measures included total narcotic usage during hospitalization.

METHODS

Institutional Review Board approval was obtained. Patients with erectile dysfunction scheduled for IPP implantation were approached for study participation. Patients were excluded if they had a previous IPP scheduled for revision or replacement or were undergoing additional procedures during the same operative session. Patients were then randomized to either DPNB with 1% lidocaine and 0.5% bupivacaine without epinephrine or injectable saline placebo. Only the resident surgeon assisting in the case was aware of randomization. All procedures were performed by a single surgeon (C.C.C.). Postoperatively, patients were asked to rate their pain using a VAS hourly while in recovery, at 4 hours, and at 23 hours postoperatively. Total narcotic usage was also measured.

RESULTS

A total of 30 patients underwent randomization with 15 patients in each group. Baseline demographic data were similar in each group. There was a significant reduction in pain in the immediate postoperative period and at 4 hours after surgery in the treatment group when compared with placebo (VAS 2.5 vs. 5.3, P = 0.009 at 0 hours; VAS 2.8 vs. 5.1, P = 0.011 at 4 hours). Narcotic usage was similar among both groups. There were no perioperative or early postoperative complications in either group.

CONCLUSIONS

DPNB is safe and effective for reducing pain in the early postoperative period following penile prosthesis implantation.

Cost analysis of robot-assisted laparoscopic versus hand-assisted laparoscopic partial nephrectomy

PURPOSE

To perform a cost comparison of three approaches to partial nephrectomy (PN): Open (OPN), hand-assisted laparoscopic (HALPN), and robot-assisted (RAPN).

PATIENTS AND METHODS

We retrospectively evaluated cost and clinical data from patients undergoing OPN, HALPN, and RAPN from 2007 to 2010 (n=89). Baseline demographic data, patient comorbidities, R.E.N.A.L. nephrometry score, and perioperative outcomes were assessed. Costs and subcosts from the operating room (OR) and hospital were evaluated using nonparametric statistical analyses.

RESULTS

Patient demographics and tumor characteristics were similar between HALPN and RAPN, while OPN patients had more comorbidities and more difficult-to-resect tumors. Thus, HALPN and RAPN were directly compared, while OPNs were excluded from the analysis. No difference was found in overall costs between HALPN and RAPN ($13,560 vs $13,439, P=0.29). OR costs were higher for RAPN ($7276 vs $5708, P=0.0001) because of the higher robotic capital and reusable equipment costs that outweighed higher disposable costs in the HALPN group. OR time-related costs were similar between groups. RAPN patients had a shorter length of stay (LOS), which decreased postoperative hospital costs ($4371 vs $5984, P=0.002).

CONCLUSIONS

No difference in overall cost was found between RAPN and HALPN. Robot allocation, OR equipment use, and LOS are important determinants of total cost. Further study regarding recovery and quality of life may reveal added benefits to minimally invasive approaches and increase use of nephron-sparing surgery.

Elimination of preoperative mechanical bowel preparation in patients undergoing cystectomy and urinary diversion

INTRODUCTION

The utility of a preoperative mechanical bowel preparation prior to bowel surgery has recently been questioned. The purpose of this study is to compare the perioperative outcomes between patients undergoing cystectomy with urinary diversion with or without preoperative mechanical bowel preparation.

METHODS

Seventy patients underwent radical cystectomy and urinary diversion between May 2008 and August 2009 for bladder cancer. The first cohort of patients (n = 37) underwent cystectomy and diversion during the period May 2008-December 2008 and underwent a preoperative mechanical bowel preparation including a clear liquid diet, magnesium citrate solution, and an enema before surgery. The second cohort of patients underwent surgery during the period of January 2009-August 2009 (n=33). These patients were given a regular diet before surgery and did not undergo a mechanical bowel preparation except for the enema before surgery was performed to decrease rectal/colonic distention. Outcome measures included gastrointestinal and overall complications, and perioperative outcomes including recovery of bowel function.

RESULTS

There were no differences with regard to recovery of bowel function, time to discharge, or overall complication rates between the 2 groups. More specifically, the rate of GI complications was not different in prepped patients vs. nonprepped patients (22% vs. 15%; P = 0.494). There were no occurrences of bowel anastomotic leak, fistula, abscess, peritonitis, or surgical site infection in either group. One perioperative death occurred in the nonprepped group secondary to cardiovascular complications.

CONCLUSIONS

Preoperative mechanical bowel preparation prior to radical cystectomy with urinary diversion does not demonstrate any significant advantage in perioperative outcomes, including gastrointestinal complications. Further studies aimed at measuring patient satisfaction and larger randomized trials will be beneficial in evaluating the role of mechanical bowel preparation prior to urinary diversion.

Urinary infections in men

Urinary tract infections are one of the most common bacterial infections and account for significant morbidity and mortality. This review of urinary infections in men provides an overview of the general presentation, diagnosis, and management of common genitourinary infections in men. The focus of this article is on clinical presentation, basic diagnostic evaluation strategies, treatment options, and when referral to a specialist is warranted.

Robot-assisted surgery: applications in urology

The past decade has seen a dramatic shift in the surgical management of certain urologic conditions with the advent of a robotic surgical platform. In fact, the surgical management of prostate cancer has seen the most dramatic shift, with the majority of cases now being performed robotically. Technical refinements over the years have led to improved outcomes regarding oncologic and functional results. Recently, robotic surgery has also been utilized for the surgical management of bladder cancer, renal cancer, and other benign conditions. As further experience is gained and longer-term outcomes are realized, robotic surgery will likely play an increasing role in the surgical management of many urologic conditions.

Robot-assisted vessel harvesting for penile revascularization

INTRODUCTION

Ideal candidates for penile revascularization include young patients with documented vasculogenic erectile dysfunction usually resulting from pelvic trauma. Historically, large midline incisions were necessary to harvest the epigastric vessels for penile revascularization. We report our experience with robot-assisted epigastric vessel harvesting for use in penile revascularization procedures.

AIM

To describe our technique and experience with robot-assisted vessel harvesting for use in penile revascularization.

METHODS

Five patients were selected for penile revascularization. Each patient suffered pelvic crush injuries resulting in post-traumatic erectile dysfunction. Each patient had no significant prior medical history and had normal erectile function prior to injury. Penile duplex Doppler ultrasound studies using vasoactive agents demonstrated decreased arterial inflow. Complementary pelvic angiography documented the corresponding arterial lesions. Each patient underwent attempted penile revascularization using a modified Virag-V technique. The epigastric artery was harvested robotically and transposed through a 3 cm incision at the base of the penis. Microscopic revascularization was performed by anastamosing the epigastric artery to the deep dorsal vein. Distal dorsal vein ligation of the subcoronal plexus was performed to limit glans hyperemia.

MAIN OUTCOME MEASURES

Description of a new method of vessel harvesting for penile revascularization.

RESULTS

Penile revascularization was successful in four out of five patients. One patient had complete thrombosis of the deep dorsal penile vein and underwent subsequent penile prosthesis implantation. Each patient undergoing successful revascularization was discharged home two days postoperatively and has reported resumption of sexual activity.

CONCLUSIONS

The robot-assisted approach to epigastric vessel harvesting is an ideal minimally-invasive complement to penile revascularization. This procedure negates the need for a large midline incision and may shorten recovery time. Our described technique offers a novel option for the application of minimally-invasive technology, but longer-term follow-up is needed to further evaluate the success of penile revascularization.

Androgen deficiency in the aging male: a guide to diagnosis and testosterone replacement therapy

A steady decline in androgen levels occurs in males as they age. Evidence suggests that this decline may be at least partially responsible for a variety of physical and mental changes associated with the aging process. For instance, abnormally low levels of androgens can lead to profound changes in bone density, body composition, as well as sexual and cognitive function. Testosterone replacement has been shown to produce improvements in many of these areas. However, this practice is not without risks, both proven and theoretic. Also, the diagnosis of androgen deficiency and the decision to treat is not always straightforward. The purpose of this article is to familiarize the clinician with issues associated with androgen deficiency in the aging male. The clinical symptoms of androgen deficiency as well as the risks and benefits of androgen replacement will be discussed. This should help clinicians better identify those patients in whom testosterone replacement therapy should be considered.

Cryotherapy after ACL reconstruction: a meta-analysis

Cryotherapy is a common treatment modality after orthopedic surgery procedures. Single institutional randomized clinical trials have evaluated the efficacy of cryotherapy after arthroscopically-assisted anterior cruciate ligament (ACL) reconstruction. Most of these studies were, however, underpowered to detect clinically relevant outcomes differences. This meta-analysis assessed the combined scientific evidence of studies evaluating the effectiveness of cryotherapy after arthroscopically-assisted ACL reconstruction. Electronic databases and bibliographic references of relevant articles were used to identify all relevant randomized clinical trials comparing cryotherapy to a placebo group after ACL reconstruction. Outcomes under investigation were postoperative drainage, range of motion, and pain. Random-effects models were used to combine the findings of the randomized controlled trials. Seven randomized clinical trials were included in the meta-analysis. Postoperative drainage (P=.23) and range of motion (P=.25) were not significantly different between cryotherapy and control group. However, cryotherapy was associated with significantly lower postoperative pain (P=.02). This meta-analysis showed that cryotherapy has a statistically significant benefit in postoperative pain control, while no improvement in postoperative range of motion or drainage was found. As the cryotherapy apparatus is fairly inexpensive, easy to use, has a high level of patient satisfaction, and is rarely associated with adverse events, we believe that cryotherapy is justified in the postoperative management of knee surgery.

Hrs interacts with sorting nexin 1 and regulates degradation of epidermal growth factor receptor

Hepatocyte growth factor-regulated tyrosine kinase substrate (Hrs) is a mammalian homologue of yeast vacuolar protein sorting (Vps) protein Vps27p; however, the role of Hrs in lysosomal trafficking is unclear. Here, we report that Hrs interacts with sorting nexin 1 (SNX1), a recently identified mammalian homologue of yeast Vps5p that recognizes the lysosomal targeting code of epidermal growth factor receptor (EGFR) and participates in lysosomal trafficking of the receptor. Biochemical analyses demonstrate that Hrs and SNX1 are ubiquitous proteins that exist in both cytosolic and membrane-associated pools, and that the association of Hrs and SNX occurs on cellular membranes but not in the cytosol. Furthermore, endogenous SNX1 and Hrs form a approximately 550-kDa complex that excludes EGFR. Immunofluorescence and subcellular fractionation studies show that Hrs and SNX1 colocalize on early endosomes. By using deletion analysis, we have mapped the binding domains of Hrs and SNX1 that mediate their association. Overexpression of Hrs or its SNX1-binding domain inhibits ligand-induced degradation of EGFR, but does not affect either constitutive or ligand-induced receptor-mediated endocytosis. These results suggest that Hrs may regulate lysosomal trafficking through its interaction with SNX1.

SNIP, a novel SNAP-25-interacting protein implicated in regulated exocytosis

Synaptosome-associated protein of 25 kDa (SNAP-25) is a presynaptic membrane protein that has been clearly implicated in membrane fusion in both developing and mature neurons, although its mechanisms of action are unclear. We have now identified a novel SNAP-25-interacting protein named SNIP. SNIP is a hydrophilic, 145-kDa protein that comprises two predicted coiled-coil domains, two highly charged regions, and two proline-rich domains with multiple PPXY and PXXP motifs. SNIP is selectively expressed in brain where it co-distributes with SNAP-25 in most brain regions. Biochemical studies have revealed that SNIP is tightly associated with the brain cytoskeleton. Subcellular fractionation and immunofluorescence localization studies have demonstrated that SNIP co-localizes with SNAP-25 as well as the cortical actin cytoskeleton, suggesting that SNIP serves as a linker protein connecting SNAP-25 to the submembranous cytoskeleton. By using deletion analysis, we have mapped the binding domains of SNIP and SNAP-25, and we have demonstrated that the SNIP-SNAP-25 association is mediated via coiled-coil interactions. Moreover, we have shown that overexpression of SNIP or its SNAP-25-interacting domain inhibits Ca(2+)-dependent exocytosis from PC12 cells. These results indicate that SNIP is involved in regulation of neurosecretion, perhaps via its interaction with SNAP-25 and the cytoskeleton.