The Future State of Race/Ethnicity in Urology: Urology Workforce Projection From 2021-2061

OBJECTIVE

To project the proportion of the urology workforce that is from under-represented in medicine (URiM) groups between 2021-2061.

METHODS

Demographic data were obtained from AUA Census and ACGME Data Resource Books. The number of graduating urology residents and proportion of URiM graduating residents were characterized with linear models. Stock and Flow models were used to project future population numbers and proportions of URiM practicing urologists, contingent on assumptions regarding trainee demographics, retirement trends, and growth in the field.

RESULTS

Currently, there is an increase in the percentage of URiM graduates by 0.145% per year. If historical trends continue, URiM urologists will likely comprise 16.2% of urology residency graduates and 13.3% of the practicing urological workforce in 2061. These percentages would constitute an underrepresentation of URiM urologists relative to the projected 44.2% of the U.S. population who would identify as American Indian/Alaskan Native, Black/African American, Latinx/Hispanic and Native Hawaiian/Pacific Islander by 2060.1 An increase in the percentage of URiM graduates by 0.845% per year would result in 44.2% URiM urology residency graduates and 26.1% URiM practicing urologists by 2061. An interactive app was designed to allow for a range of assumptions to be explored and for future data to be incorporated.

CONCLUSION

URiM physician representation within urology over the next 40years will remain disproportionately low compared to that of the projected share of people of color in the general U.S.

POPULATION

In order to achieve the AUA's Diversity, Equity and Inclusion goals, a concerted effort to implement interventions to recruit, train, and retain a generation of racially diverse urologists appears necessary.

Someone Like Me: An Examination of the Importance of Race-Concordant Mentorship in Urology

OBJECTIVE

To describe differences in urology mentorship exposure for medical students across race/ethnicity and to explore how much potential mentees valued the importance of race-concordant mentorship.

METHODS

All medical students at UCLA received a cross-sectional survey. Dependent variables were perceived quality of mentorship in urology and association between race-concordant mentorship and perceived importance of race-concordant mentorship. Mentors were self-selected by medical students. Variables were compared across race/ethnicity using descriptive statistics and multivariate analyses. Subset analyses looking at race-concordance between mentor and student was performed using stratified Cochran-Mantel-Haenszel tests. This was performed to determine if there were differences, across race/ethnicity, in rating of importance of having a race-concordant mentor.

RESULTS

The likelihood of having a urologist as a mentor was similar across race/ethnicity. Under-Represented in Medicine (URiM) students were more likely to report that having a mentor of the same race/ethnicity was extremely important (Asian 9%, Black 58%, Latinx 55% and White 3%, P < .001) compared to their non-URiM peers who were more likely to rate having a race-concordant mentor as not at all important (Asian 34%, Black 5%, Latinx 8%, White 79%, P < .001). URiM students with race-concordant mentors were still more likely to rate having a mentor of the same race/ethnicity as extremely/very important (73%) compared to their non-URiM peers (9%, P = .001). URiM students with race-discordant mentors also rated importance of mentors of the same race/ethnicity as extremely/very important (67%) compared to their non-URiM peers (11%, P = .006).

CONCLUSION

URiM medical students regard race-concordant mentorship as extremely important. Interventions addressing mentor racial/ethnic concordance and those promoting culturally responsive mentorship may optimize recruitment of URiM students into urology.

Racial and Ethnic Differences in Medical Student Timing and Perceived Quality of Exposure to Urology

OBJECTIVE

To contextualize the low representation of Under-Represented in Medicine (URiM) in urology, we examine differences in timing and perceived quality of urology clinical and research exposures for medical students across race/ethnicity.

METHODS

A cross-sectional survey was distributed to all medical students at UCLA. Dependent variables were timing of urology exposure and perceived quality of urology exposure. Descriptive statistics and multivariate analyses were used to compare variables across race/ethnicity. Logistic regression was used to determine odds of early exposure to urology across race/ethnicity.

RESULTS

Black and Latinx students were significantly less likely to discover urology before MS3 (P<.001). Although URiM students were more likely to recall receiving a urology interest group invitation (Asian 46%, Black 53%, Latinx 67%, White 48%, P=.03), they were less likely to attend an event (Asian 23%, Black 4%, Latinx 3% and White 15%, P<.001) despite being more likely to be interested in urology (Asian 32%, Black 38%, Latinx 50%, White 28%, P=.01). Black students were more likely to gain exposure via family/friend with a urological diagnosis. Black and Latinx students were twice as dissatisfied with timing and method of medical school exposure to urology versus their peers. There were differences across race/ethnicity for whether or not a student had engaged in urology research (Asian 10%, Black 5%, Latinx 2%, White 2%, P=.01).

CONCLUSIONS

Racial/ethnic disparities exist in early exposure to urology, involvement in urology interest group, access to research, and satisfaction with exposure to urology. Interventions addressing the timing and quality of urology exposures may optimize recruitment of URiM students into urology.

Decisional Regret and Financial Toxicity among Patients with Benign Renal Masses

INTRODUCTION

Treatment of benign renal masses may often be unnecessary and can lead to significant morbidity, mortality, and health care costs. However, individual burdens such as decisional regret and financial costs associated with treatment are not well understood.

METHODS

Members of a support group who have been diagnosed with benign renal tumors were surveyed to evaluate demographic and clinical characteristics as well as decisional regret, using the modified Decision Regret Scale (DRS), and financial toxicity, using the Comprehensive Score for Financial Toxicity (COST). Predictors of decisional regret (DRS score >25) and financial toxicity were explored using logistic and linear regression analyses, respectively.

RESULTS

Of 70 respondents with complete data, 49 (70%) received definitive treatment while 21 (30%) elected surveillance. Decisional regret was expressed by 34/70 (49%) of patients and was associated with increasing age, smaller tumor size, and use of surveillance vs active treatment in univariable analysis. Patients reported significant financial toxicity from the diagnosis of a benign renal mass with a median COST score of 24, similar to a historical cohort of patients with stage IV solid organ cancers undergoing chemotherapy. Qualitative analysis of patient responses identified a lack of discussion by the provider of the likelihood of benign disease, postoperative complications, and financial burden as common themes in their experiences.

CONCLUSIONS

High levels of decisional regret and financial toxicity were found among individuals with benign renal lesions regardless of treatment approach. Improved counseling and diagnostic tools may limit the psychological and financial burdens from these benign entities.

Comparison of Response to Definitive Radiotherapy for Localized Prostate Cancer in Black and White Men: A Meta-analysis

IMPORTANCE

Black men have a 2-fold increased risk of dying from prostate cancer compared with White men. However, race-specific differences in response to initial treatment remain unknown.

OBJECTIVE

To compare overall and treatment-specific outcomes of Black and White men with localized prostate cancer receiving definitive radiotherapy (RT).

DATA SOURCES

A systematic search was performed of relevant published randomized clinical trials conducted by the NRG Oncology/Radiation Therapy Oncology Group between January 1, 1990, and December 31, 2010. This meta-analysis was performed from July 1, 2019, to July 1, 2021.

STUDY SELECTION

Randomized clinical trials of definitive RT for patients with localized prostate cancer comprising a substantial number of Black men (self-identified race) enrolled that reported on treatment-specific and overall outcomes.

DATA EXTRACTION AND SYNTHESIS

Individual patient data were obtained from 7 NRG Oncology/Radiation Therapy Oncology Group randomized clinical trials evaluating definitive RT with or without short- or long-term androgen deprivation therapy. Unadjusted Fine-Gray competing risk models, with death as a competing risk, were developed to evaluate the cumulative incidences of end points. Cox proportional hazards models were used to evaluate differences in all-cause mortality and the composite outcome of distant metastasis (DM) or death. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline was followed.

MAIN OUTCOMES AND MEASURES

Subdistribution hazard ratios (sHRs) of biochemical recurrence (BCR), DM, and prostate cancer-specific mortality (PCSM).

RESULTS

A total of 8814 patients (1630 [18.5%] Black and 7184 [81.5%] White) were included; mean (SD) age was 69.1 (6.8) years. Median follow-up was 10.6 (IQR, 8.0-17.8) years for surviving patients. At enrollment, Black men were more likely to have high-risk disease features. However, even without adjustment, Black men were less likely to experience BCR (sHR, 0.88; 95% CI, 0.58-0.91), DM (sHR, 0.72; 95% CI, 0.58-0.91), or PCSM (sHR, 0.72; 95% CI, 0.54-0.97). No significant differences in all-cause mortality were identified (HR, 0.99; 95% CI, 0.92-1.07). Upon adjustment, Black race remained significantly associated with improved BCR (adjusted sHR, 0.79; 95% CI, 0.72-0.88; P < .001), DM (adjusted sHR, 0.69; 95% CI, 0.55-0.87; P = .002), and PCSM (adjusted sHR, 0.68; 95% CI, 0.50-0.93; P = .01).

CONCLUSIONS AND RELEVANCE

The findings of this meta-analysis suggest that Black men enrolled in randomized clinical trials present with more aggressive disease but have better BCR, DM, and PCSM with definitive RT compared with White men, suggesting that other determinants of outcome, such as access to care, are important factors of achieving racial equity.

Diversifying Graduate Medical Education & the Urology Workforce: Re-imagining our Structures, Policies, Practices, Norms, & Values

This article offers a framework for critically examining the structures, policies, norms, practices, and values that shape the Urology Match as a foundation for interventions to improve diversity, equity, inclusion, and justice in the workforce. Points of leverage for transformational change in the urology workforce diversification include modifying the structure of the urology application process, optimizing reviewer factors, addressing Under-Represented in Medicine applicant experience, providing resources to applicants, and evaluating selection criteria. To achieve an inclusive diverse urology workforce, we must change policy and practice, expand what we include in the norm, which will translate into increased value ascribed to a more varied cohort of applicants, leading to the establishment of structures that accommodate true diversity.

Perceptions of partial gland ablation for prostate cancer among men on active surveillance: A qualitative study

OBJECTIVES –

Partial gland ablation (PGA) therapy is an emerging treatment modality that targets specific areas of biopsy proven prostate cancer (PCa) to minimize treatment-related morbidity by sparing benign prostate. This qualitative study aims to explore and characterize perceptions and attitudes toward PGA in men with very-low-risk, low-risk, and favorable intermediate-risk PCa on active surveillance (AS).

DESIGN –

92 men diagnosed with very-low-risk, low-risk, and favorable intermediate-risk PCa on AS were invited to participate in semi-structured telephone interviews on PGA.

SETTING –

Single tertiary care center located in New York City.

PARTICIPANTS –

20 men with very-low-risk, low-risk, and favorable intermediate-risk PCa on AS participated in the interviews.

MAIN OUTCOME MEASURES –

Emerging themes on perceptions and attitudes toward PGA were developed from transcripts inductively coded and analyzed under standardized methodology.

RESULTS –

Four themes were derived from twenty interviews that represent the primary considerations in treatment decision-making: (1) the feeling of psychological safety associated with low-risk disease; (2) preference for minimally invasive treatments; (3) the central role of the physician; (4) and the pursuit of treatment options that align with disease severity. Eleven men (55%) expressed interest in pursuing PGA only if their cancer were to progress, while 9 men (45%) expressed interest at the current moment.

CONCLUSIONS –

Though an emerging treatment modality, patients were broadly accepting of PGA for PCa with men primarily debating the risks versus benefits of proactively treating low-risk disease. Additional research on men's preferences and attitudes toward PGA will further guide counseling and shared decision-making for PGA.

Cost-effectiveness analysis of pembrolizumab for BCG-unresponsive carcinoma in situ of the bladder

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Background: Patients with BCG-unresponsive carcinoma in situ (CIS) are treated with radical cystectomy (RCx) or salvage intravesical chemotherapy (SIC). Recently, the FDA approved pembrolizumab for BCG-unresponsive CIS +/- papillary tumors. Given the costs and toxicities of pembrolizumab, it remains unclear whether its benefits are sufficient to warrant widespread use for BCG-unresponsive CIS. To that end, we conducted a cost-effectiveness analysis comparing pembrolizumab with RCx and SIC (using gemcitabine-docetaxel as the prototypical regimen) for patients with BCG-unresponsive CIS. Methods: A decision-analytic Markov model compared pembrolizumab, SIC (with gemcitabine-docetaxel), and RCx for patients with BCG-unresponsive CIS +/- papillary tumors who are RCx candidates (index patient 1) or are unwilling/unable to undergo RCx (index patient 2). Each treatment option was a Markov node containing distinct variations of the following health states: surveillance, recurrence, progression to MIBC, progression to metastasis, treatment toxicity, and death. Incremental Cost-Effectiveness Ratios (ICERs) were compared using a willingness-to-pay threshold of $100,000/Quality-adjusted life year (QALY). The model used a US Medicare perspective with a 5-year time horizon for the base case. One-way and probabilistic sensitivity analyses were performed for all model parameters. Results: For index patient 1, pembrolizumab was not cost-effective vs. RCx (ICER $1,403,008) or SIC (ICER $2,011,923). One-way sensitivity analysis revealed that pembrolizumab only became cost-effective relative to RCx with a > 93% price reduction. Relative to RCx, SIC was cost-effective for time horizons < 5 years and nearly cost-effective at 5 years (ICER $118,324). One-way sensitivity analysis revealed that SIC became cost-effective relative to RCx if its risk of recurrence or metastasis at 2 years was less than 55% or 5.9%, respectively. For index patient 2, pembrolizumab required > 90% price reduction to be cost-effective vs. RCx (ICER $1,073,240). Probabilistic sensitivity analyses revealed that pembrolizumab was unlikely to be cost-effective even at high willingness-to-pay thresholds. Further sensitivity analyses found that no two-way combination of extrapolated values resulted in pembrolizumab being favored over RCx or SIC for either index patient. Conclusions: Based on decision-analytic Markov modeling of treatment options for patients with BCG-unresponsive CIS, pembrolizumab was unlikely to be cost-effective without a > 90% price reduction. While both RCx and SIC were more cost-effective than pembrolizumab, further studies may validate the cost-effectiveness of gemcitabine-docetaxel relative to RCx if the recurrence and metastasis thresholds are met. Overall, our model supports the preferential use of RCx and SIC over pembrolizumab for BCG-unresponsive CIS.

Association of reductions in PSA screening across states with increased metastatic prostate cancer in the United States

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Background: While PSA screening was found to reduce prostate cancer metastasis and mortality in a large European randomized trial, PSA screening has also resulted in over-treatment of prostate cancer with significant quality-of-life implications. As a result, the US Preventive Services Task Force (USPSTF) did not recommend PSA screening in 2008 and 2012. It is unknown if reductions in PSA screening were responsible for increased metastatic prostate cancer in the United States. We test this hypothesis by associating longitudinal variations across individual states in PSA screening with their incidence of metastatic prostate cancer at diagnosis from 2002 to 2016. Methods: Age-adjusted incidences of metastatic prostate cancer at diagnosis per 100,000 men were obtained from the North American Association of Central Cancer Registries in 2002 – 2016 for each state. Survey-weighted PSA screening estimates for each state were extracted from the Behavioral Risk Factor Surveillance System, which collects this information for men at least 40 years of age every 2 years from 2002 onward. PSA screening and metastasis data were collated as a multi-panel time series and then analyzed using a random-effects linear regression model with random effects at the state level. Results: There was significant variation between states in the percent of men age >40 years who reported ever receiving PSA screening (range 40.1% to 70.3%) and in the age-adjusted incidence of metastatic prostate cancer at diagnosis (range 3.3 to 14.3 per 100,000). From 2008 to 2016, the mean percentage of men screened decreased (61.8% to 50.5%) whereas the mean incidence of metastatic prostate cancer at diagnosis increased (6.4 to 9.0 per 100,000; Bonferroni adjusted p < 0.001 for both). A random-effects linear regression model demonstrated that longitudinal reductions across states in PSA screening were associated with increased metastatic prostate cancer (regression coefficient per 100,000 men: 14.9, 95% CI 12.3 – 17.5, p < 0.001). This indicated that states with larger declines in PSA screening had larger increases in the incidence of metastatic prostate cancer at diagnosis. Variation in PSA screening explained 27% of the longitudinal variation in metastatic prostate cancer within states. Conclusions: In the context of randomized trial data demonstrating a metastasis reduction with PSA screening, our study strengthens the epidemiologic evidence that reductions in PSA screening may explain some of the recent increase in metastatic prostate cancer at diagnosis in the United States. The trend of rising metastatic disease at diagnosis is a worrisome consequence that needs attention. Thus, we support shared-decision making policies, such as the 2018 USPSTF update, that may optimize PSA screening utilization to reduce the incidence of metastatic prostate cancer in the United States.

The Use of 3-Dimensional, Virtual Reality Models for Surgical Planning of Robotic Partial Nephrectomy

OBJECTIVE

To determine whether 3-dimensional virtual reality models of patient-specific anatomy improve outcomes in patients undergoing robotic partial nephrectomy.

MATERIALS AND METHODS

Computed tomography and magnetic resonance imaging scans for 30 patients undergoing robotic partial nephrectomy were converted to 3-dimensional virtual reality models prior to the patient's operation. These models were then viewed on the surgeon's mobile phone pre- and intraoperatively using a Google Cardboard headset to assist in surgical planning. This group was compared to 30 patients who previously underwent robotic partial nephrectomy. We compared operative time, clamp time, estimated blood loss, hospital stay, complications, and margin status between these groups. We used forward selecting multivariate regression models to create the final model controlling for significant demographic and clinical variables.

RESULTS

When controlling for case complexity and surgeon, patients with 3-dimensional, virtual reality-assisted surgical planning had significantly lower operative time (141 minutes vs 201 minutes, P < .0001), clamp time (13.2 minutes vs 17.4 minutes, P = .0274), and estimated blood loss (134 cc vs 259 cc, P = .0233). Patients without 3-dimensional, virtual reality-assisted surgical planning were more likely to have a hospital stay of greater than 2 days (odds ratio 5.1, 95% confidence interval 1.0, 26.4). There were no complications or positive margins noted in the VR group.

CONCLUSION

Use of a 3-dimensional, virtual reality model when performing robotic partial nephrectomy improves key surgical outcome parameters.

Decisional Quality in Patients With Small Renal Masses

OBJECTIVE

To measure decisional quality in patients being counseled on treatment for small renal masses and identify potential areas of improvement.

MATERIALS AND METHODS

A total of 73 patients diagnosed with small renal masses at the University of California, Los Angeles Health completed an instrument measuring decisional conflict, patient satisfaction with care, disease-specific knowledge, and patient impression that shared decision-making occurred in the visit after counseling by a specialist. Participant characteristics were compared between those with high and low decisional conflict using chi-square or Student t test (or Wilcoxon rank-sum test).

RESULTS

Participants were mostly older (mean age 63.5), white (84%), in a relationship (61%), and unemployed or retired (63%). Mean knowledge score was 59% correct. The mean (standard deviation) decisional conflict score was 16.4 (18.4) indicating low levels of decisional conflict but with a wide range of scores. Comparing participants with high decisional conflict with those with low decisional conflict, there were significant differences in knowledge scores (Wilcoxon P = .0069), patient satisfaction with care (P = .0011), and perceived shared decision-making (P <.0001).

CONCLUSION

Patients with small renal masses generally have low levels of decisional conflict and can identify a preferred treatment after a physician visit. However, both groups lack overall knowledge about their disease even after counseling, and thus may be heavily influenced by paternalistic care. Those patients with decisional conflicts are less likely to perceive their care as satisfactory and are less likely to be involved in decision-making.

Costs and of treating Gleason score 9 and 10 prostate cancer vary widely based on need for adjuvant therapy: A critical assessment into the long-term cost implications of additional treatment modalities

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Background: The costs of treating localized, Gleason score 9 and 10 prostate cancer remain poorly described, especially when the particularly aggressive nature of the disease often requires a multimodal approach. We report the results of time-driven activity-based costing to assess the long-term costs of treating this subset of patients with either RALP, high-dose EBRT, or EBRT with a high-dose rate brachytherapy (BT) boost. Methods: Based on a multi-institutional cohort of 487 patients with Gleason score 9-10 prostate cancer, we generated process maps for each phase of care from the initial urologic visit through a median follow-up of 3.76 years, incorporating all prostate cancer treatment over this horizon. Costs were calculated per unit time, and the proportion of capacity for each step was determined. TDABC was defined as the sum of its resources. Results: Substantial cost variation was demonstrated between treatment modalities with an estimated median cost of $49,681 for EBRT, $35,140 for RALP, and $31,647 for EBRT + BT at 3.76 years. The primary driver in cost variation was the use of ADT. RALP (170 pts) ranged from $18,896 (29.5%) for no postoperative therapy to $63,270 for immediate long-term ADT (5.3%). EBRT (230 pts) had the greatest cost variation [Table 1]. Finally, EBRT + BT (336 pts) ranged from $26,522 for EBRT + BT alone (12.6%) to $37,834 for EBRT + BT + salvage ADT + HIFU (1.2%). Conclusions: Characterizing the costs associated with the distribution of treatments for men with high-risk prostate cancer is essential as we move towards health care accountability. There is substantial long-term cost variation between treatments in this subset of patients, and understanding these differences may affect treatment implications as we shift toward accountable payment models.[Table: see text]

Use of the Electronic Medical Record to Facilitate Intervention for Patients With Rising Prostate-Specific Antigen Values After Radical Prostatectomy: A Feasibility Study

PURPOSE

Salvage radiotherapy (SRT) is the standard of care offered when postprostatectomy prostate-specific antigen (PSA) levels are ≥ 0.2 ng/mL. However, emerging evidence suggests that early SRT (ie, SRT delivered at PSA values < 0.2 ng/mL, but generally ≥ 0.05 ng/mL) improves oncologic outcomes. We evaluated the feasibility of improving referral rates for discussion of early SRT by using a dynamic registry that identifies through the electronic medical record patients with rising postprostatectomy PSA levels.

METHODS

We developed an iteratively updated registry that identifies patients who fall within two postoperative PSA strata: ≥ 0.05 to < 0.1 ng/mL and ≥ 0.1 to < 0.2 ng/mL. We compared referral rates to radiation oncology during a 3-year period before use of this registry with those during a 1-year period after promotion of the registry in multidisciplinary tumor board settings.

RESULTS

Before promotion of the registry, referral rates for patients with PSA values ≥ 0.05 to < 0.1 ng/mL and ≥ 0.1 to < 0.2 ng/mL were 35% and 65%, respectively. After promotion of the registry, referral rates within each stratum increased significantly to 82% and 94%, respectively ( P < .05 for both by Fisher's exact test). The overall rate of referral for patients with PSA values ≥ 0.05 to < 0.2 ng/mL rose from 48% to 90% ( P < .001).

CONCLUSION

The creation of a registry of patients with rising postprostatectomy PSA values can facilitate increased referral rates for early SRT without burdening providers with a clinical support tool embedded within the EMR itself. This is true even in the case of already high baseline rates of referral for early SRT. The changes reported herein most likely reflect a Hawthorne effect wherein the ability to track referrals rather than a direct function of the registry influenced practice patterns. Nonetheless, the registry provided an integral framework to allow for tracking.

TrueNTH sexual recovery study protocol: a multi-institutional collaborative approach to developing and testing a web-based intervention for couples coping with the side-effects of prostate cancer treatment in a randomized controlled trial

BACKGROUND

Over half of men who receive treatment for prostate suffer from a range of sexual problems that affect negatively their sexual health, sexual intimacy with their partners and their quality of life. In clinical practice, however, care for the sexual side effects of treatment is often suboptimal or unavailable. The goal of the current study is to test a web-based intervention to support the recovery of sexual intimacy of prostate cancer survivors and their partners after treatment.

METHODS

The study team developed an interactive, web-based intervention, tailored to type of treatment received, relationship status (partnered/non-partnered) and sexual orientation. It consists of 10 modules, six follow the trajectory of the illness and four are theme based. They address sexual side effects, rehabilitation, psychological impacts and coaching for self-efficacy. Each includes a video to engage participants, psychoeducation and activities completed by participants on the web. Tailored strategies for identified concerns are sent by email after each module. Six of these modules will be tested in a randomized controlled trial and compared to usual care. Men with localized prostate cancer with partners will be recruited from five academic medical centers. These couples (N = 140) will be assessed prior to treatment, then 3 months and 6 months after treatment. The primary outcome will be the survivors' and partners' Global Satisfaction with Sex Life, assessed by a Patient Reported Outcome Measure Information Systems (PROMIS) measure. Secondary outcomes will include interest in sex, sexual activity, use of sexual aids, dyadic coping, knowledge about sexual recovery, grief about the loss of sexual function, and quality of life. The impact of the intervention on the couple will be assessed using the Actor-Partner Interaction Model, a mixed-effects linear regression model able to estimate both the association of partner characteristics with partner and patient outcomes and the association of patient characteristics with both outcomes.

DISCUSSION

The web-based tool represents a novel approach to addressing the sexual health needs of prostate cancer survivors and their partners that-if found efficacious-will improve access to much needed specialty care in prostate cancer survivorship.

TRIAL REGISTRATION

Clinicaltrials.gov registration # NCT02702453 , registered on March 3, 2016.

AUA White Paper on Implementation of Shared Decision Making into Urological Practice

INTRODUCTION

Shared decision making is a collaborative approach to care that seeks to improve the quality of medical decisions by helping patients choose options concordant with their values and in accordance with the best available scientific evidence.

METHODS

A literature review was performed targeting publications between 2003 and 2014 on the topic of shared decision making and decision aids for urological conditions. An expert panel was convened to evaluate this information and create this white paper with the purpose of educating the urological community on these issues.

RESULTS

Shared decision making represents the state of the art in patient counseling. Patients who have engaged in shared decision making have greater knowledge and satisfaction as well as greater engagement with care. Numerous organizations make available free resources for shared decision making including decision aids and tools to evaluate the quality of shared decision making.

CONCLUSIONS

Shared decision making is an important component of high quality health care delivery and future reimbursement models. In appropriate circumstances urologists should adopt shared decision making into routine clinical practice.

Outcomes of Sacral Neuromodulation in a Privately Insured Population

OBJECTIVE

In this study, we analyzed claims data from the Ingenix data base to analyze outcomes of sacral neuromodulation with respect to both provider and patient factors.

MATERIALS AND METHODS

We used the Ingenix (I3) data base to determine demographic, diagnosis, and procedure success information for years 2002-2007 for privately insured patients. Demographic information was obtained, as were the diagnoses given and procedures performed, based on ICD-9 diagnosis codes and Current Procedural Terminology procedure codes. Multivariate analysis was performed to identify specific predictors of success, as measured by progression to implantation of a pulse generator.

RESULTS

Overall success, as defined by battery placement, was 49.1%. Fifty-one percent of staged procedures were followed by battery placement compared with 24.1% of percutaneous cases (p < 0.0001). Among the patient variables analyzed, women were more likely than men to progress to battery placement. After Stage I testing, patients treated by urologists were overall more likely than gynecologists to proceed to battery placement (I3: 54% vs. 47%, p < 0.0001). Unlike previous findings in other claims-based data sets, we did not observe a provider-volume relationship in the i3 data set.

CONCLUSIONS

Success of sacral neuromodulation, as defined by proceeding to battery placement, was much better after formal staged procedures, which leads us to question the utility of percutaneous techniques. Outcomes were also better among female patients and among those treated by a urologist. Specialty differences will likely diminish over time as more gynecologists adopt sacral neuromodulation.

Pre-treatment nomogram to predict potency after treatment for localized prostate cancer

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Background: Radical prostatectomy (RP), external beam radiotherapy (EBRT), and brachytherapy are commonly utilized treatments for localized prostate cancer and may negatively impact sexual function to varying degrees. Patient-, disease-, and treatment-specific factors may all impact post-treatment sexual function. We aimed to evaluate predictors of post-treatment impotency, and develop a prognostic nomogram using prospective, patient-reported data from multiple validated health-related quality-of-life (HRQOL) instruments. Methods: Between 1999 and 2011, patient-reported data regarding treatment-related effects on erectile function were obtained from 2668 patients enrolled in one of four prospective longitudinal HRQOL protocols from the United States and Spain. Patients were treated with RP (n=1,294), EBRT (n=630), or brachytherapy (n=744). Although different HRQOL instruments were used in each protocol, questions pertaining to quality and frequency of erections were identical across the different instruments. Patient responses were obtained at baseline and 2 years after treatment. The endpoint of the model was impotency at 2 years post-treatment. Logistic regression analysis was used to model clinical information and outcome data. Internal validation was performed using bootstrapping. Results: 1,306 patients were potent at baseline and had 24-month follow-up. Differences in baseline patient characteristics such as patient age, ethnicity, and disease severity existed between the treatment groups. The impotency rate at 2 years was 62%, 53%, and 41% for patients treated by RP, EBRT, and brachytherapy, respectively. In multivariable analysis, age, PSA, modality of treatment, frequency of preoperative erections, diabetes, and hypertension were associated with post-treatment impotency (all p<0.05). A nomogram based on the predictive parameters had a concordance index of 0.726 and predictions were well-calibrated with observed outcome. Conclusions: A validated nomogram that predicts 2-year risk of impotency after treatment of localized prostate cancer has been developed and is anticipated to be useful for patient counseling regarding treatment options.

Expectant management of veterans with early-stage prostate cancer

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Background: We evaluated the association between various factors and the use of expectant management (EM) among patients with prostate cancer treated in the Veterans Health Administration. Methods: We identified men diagnosed with prostate cancer in 2008. Outcome of interest was use of EM captured through an in-depth chart review. We fit multivariable regression models to examine associations between EM use and patient demographics, cancer severity, and facility characteristics. We then assessed regional variation across 52 facilities by generating predicted probabilities for receipt of EM. Results: Among our analytic cohort (n=6,540), 34% of men were treated expectantly. EM was more common among patients 75 and older (40% vs. 27% under 55 years, OR 2.57) and with low-risk tumors (49% vs. 20% high-risk, OR 5.35). There was no association between patient comorbidity and receipt of EM (p=0.90) (Table). There were also no significant associations between facility factors and receipt of EM (all p>0.05). Among ideal EM candidates, receipt of expectant management varied considerably across individual facilities (0 – 85%, p<0.001). Conclusions: Patient age and tumor risk were both more strongly associated with the use of expectant EM than patient comorbidity. Though its appears appropriate broadly, there was variation in EM between hospitals, apparently not attributable to facility factors. Research determining the basis of this variation—with a focus on providers—will be critical to help optimize prostate cancer treatment for veterans. [Table: see text]

Time-driven activity-based costing: a driver for provider engagement in costing activities and redesign initiatives

OBJECT

To date, health care providers have devoted significant efforts to improve performance regarding patient safety and quality of care. To address the lagging involvement of health care providers in the cost component of the value equation, UCLA Health piloted the implementation of time-driven activity-based costing (TDABC). Here, the authors describe the implementation experiment, share lessons learned across the care continuum, and report how TDABC has actively engaged health care providers in costing activities and care redesign.

METHODS

After the selection of pilots in neurosurgery and urology and the creation of the TDABC team, multidisciplinary process mapping sessions, capacity-cost calculations, and model integration were coordinated and offered to engage care providers at each phase.

RESULTS

Reviewing the maps for the entire episode of care, varying types of personnel involved in the delivery of care were noted: 63 for the neurosurgery pilot and 61 for the urology pilot. The average cost capacities for care coordinators, nurses, residents, and faculty were $0.70 (range $0.63-$0.75), $1.55 (range $1.28-$2.04), $0.58 (range $0.56-$0.62), and $3.54 (range $2.29-$4.52), across both pilots. After calculating the costs for material, equipment, and space, the TDABC model enabled the linking of a specific step of the care cycle (who performed the step and its duration) and its associated costs. Both pilots identified important opportunities to redesign care delivery in a costconscious fashion.

CONCLUSIONS

The experimentation and implementation phases of the TDABC model have succeeded in engaging health care providers in process assessment and costing activities. The TDABC model proved to be a catalyzing agent for cost-conscious care redesign.

Building the Infrastructure for Value at UCLA: Engaging Clinicians and Developing Patient-Centric Measurement

PROBLEM

Evolving payer and patient expectations have challenged academic health centers (AHCs) to improve the value of clinical care. Traditional quality approaches may be unable to meet this challenge.

APPROACH

One AHC, UCLA Health, has implemented a systematic approach to delivery system redesign that emphasizes clinician engagement, a patient-centric scope, and condition-specific, clinician-guided measurement. A physician champion serves as quality officer (QO) for each clinical department/division. Each QO, with support from a central measurement team, has developed customized analytics that use clinical data to define targeted populations and measure care across the full treatment episode.

OUTCOMES

From October 2012 through June 2015, the approach developed rapidly. Forty-three QOs are actively redesigning care delivery protocols within their specialties, and 95% of the departments/divisions have received a customized measure report for at least one patient population. As an example of how these analytics promote systematic redesign, the authors discuss how Department of Urology physicians have used these new measures, first, to better understand the relationship between clinical practice and outcomes for patients with benign prostatic hyperplasia and, then, to work toward reducing unwarranted variation. Physicians have received these efforts positively. Early outcome data are encouraging.

NEXT STEPS

This infrastructure of engaged physicians and targeted measurement is being used to implement systematic care redesign that reliably achieves outcomes that are meaningful to patients and clinicians-incorporating both clinical and cost considerations. QOs are using an approach, for multiple newly launched projects, to identify, test, and implement value-oriented interventions tailored to specific patient populations.

Variation in treatment associated with life expectancy in a population-based cohort of men with early-stage prostate cancer

BACKGROUND

Men with major comorbidities are at risk for overtreatment of prostate cancer due to uncertainty regarding their life expectancy. We sought to characterize life expectancy and treatment in a population-based cohort of men with differing ages and comorbidity burdens at diagnosis.

METHODS

We sampled 96,032 men aged ≥66 years with early-stage prostate cancer who had Gleason scores ≤7 and were diagnosed during 1991 to 2007 from the Surveillance, Epidemiology, and End Results-Medicare database. We calculated cumulative incidence of other-cause mortality and determined treatment patterns among subgroups defined by age and Charlson comorbidity index scores.

RESULTS

Overall, life expectancy was <10 years (10-year other-cause mortality rate, >50%) for 50,049 of 96,032 men (52%). Life expectancy differed by age and comorbidity score and was <10 years for men ages 66 to 69 years with Charlson scores ≥2, for men ages 70 to 74 years with Charlson scores ≥1, and for all men ages 75 to 79 years and ≥80 years. Among those who had a life expectancy <10 years, treatment was aggressive (surgery, radiation, or brachytherapy) for 68% of men aged 66 to 69 years, 69% of men aged 70 to 74 years, 57% of men aged 75 to 79 years, and 24% of men aged ≥80 years. Among these men, aggressive treatment was predominantly radiation therapy (50%, 53%, 63%, and 69%, respectively) and less frequently was surgery (30%, 25%, 13%, and 9%, respectively). Multivariate models revealed little variation in the probability of aggressive treatment by comorbidity status within age subgroups despite substantial differences in mortality.

CONCLUSIONS

Men aged <80 years at diagnosis who have life expectancies <10 years often receive aggressive treatment for low-risk and intermediate-risk prostate cancer, mostly with radiation therapy.